2024 Elderplan_HomeFirst Sales Presentation

Leading the way to great care.SM

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, provider network and pharmacy 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.

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

About Elderplan

4 Elderplan is a member of MJHS Health System, a not-for-profit health care organization, founded in 1907 by the Four Brooklyn Ladies based on the core values of compassion, dignity and respect. MJHS has a rich history of caring for at-risk New Yorkers of every race, ethnicity, faith, national origin, gender identity or expression, sexual orientation and military status.

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. Our primary objective is ensuring that members of our community receive the care and support they deserve

4 One of the many advantages of being an Elderplan/HomeFirst member is that we are part of the MJHS Health System family that includes: MJHS Home Care, MJHS Hospice and Palliative Care, as well as MJHS Isabella and MJHS Menorah Centers for Rehabilitation and Nursing Care. So, if you need access to additional support over time, and choose to receive services from MJHS, your Elderplan team can work together with their colleagues from across the system to better coordinate your care and make it easier for you.

4 Elderplan realizes that staying healthy is not always as easy as seeing the doctor or taking medications as prescribed. Unfortunately, gaps in access to quality health care based on race, ethnicity and financial stability are still all too often a factor. Consistent with our values, Elderplan is leading the way to great care by being committed to health equity, to closing these gaps in care, and ensuring that all our members have access to high-quality programs and services.

4 Includes more than 193,035 provider locations in our network and you can now see any Specialist or Dentist —even out-of-network, at no additional cost.

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

Let’s discuss your current coverage and needs!

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 Comprehensive Dental important to you?

4 Do you need assistance with Long-Term Care services at home?

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

4 Is seeing any Specialist or Dentist at no extra cost 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-POS D-SNP):

A health plan designed specifically for Medicare beneficiaries who also have Medicaid that offers medical, hospital, and prescription drug coverage—all in one simple plan. Plus, extra benefits like the ability to see any Dentist or Specialist at no extra cost, expanded over-the-counter (OTC)* benefits, a Flex spending card, and a dedicated Care Manager who will be there to support and guide you by helping to coordinate your benefits, answer your questions and more.

Members of this plan will also be able to participate in our Wellness Incentive Program that rewards you for receiving eligible screenings and vaccinations, receive a gym membership to help you stay healthy, and have access to our award-winning Member-to-Member program.

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

A health plan designed specifically for Medicare and Medicaid beneficiaries who need long-term care at home and want their long-term care services, medical, hospital and prescription drug coverage all together in one simple plan. You will have the ability to see any Dentist or Specialist at no extra cost, receive new expanded over-the-counter (OTC)* benefits, a Flex spending card, and be assigned a dedicated Care Manager who will be there to support and guide you, by helping to coordinate your benefits, answer your questions and more.

Members of this plan will also be able to participate in our Wellness Incentive Program that rewards you for receiving eligible screenings and vaccinations, receive a gym membership to help you stay healthy, and have access to our award-wining Member-to-Member program.

* The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify

Our Plans - Highlights

4 Elderplan Extra Help (HMO-POS):

A health plan designed specifically for Medicare beneficiaries who are eligible for Extra Help. This plan offers medical, hospital, and prescription drug coverage at little-or-no premium and low copays. Plus, extra benefits like the ability to see any Dentist or Specialist at no extra cost, a new expanded OTC*, Flex spending card, and a dedicated Care Management Team that will be there to support and guide you, by helping to coordinate your benefits, answer your questions and more.

Members of this plan will also be able to participate in our Wellness Incentive Program that rewards you for receiving eligible screenings and vaccinations, receive a gym membership to help you stay healthy, and have access to our award-winning Member-to-Member program.

4 Elderplan Flex (HMO-POS):

A health plan designed specifically for Medicare beneficiaries that offers the flexibility to choose the benefits and doctors you want. In addition to offering medical, hospital and prescription drug coverage, this plan allows you to pick between Over-the-Counter (OTC)* benefit OR Transportation benefit to and from medical appointments. You can even see any Specialist or Dentist at no extra cost and have a dedicated Care Management Team that will be there to support and guide you, by helping to coordinate your benefits, answer your questions, and more.

Members of this plan will also be able to participate in our, Wellness Incentive Program that rewards you for receiving eligible screenings and vaccinations, receive a gym membership to help you stay healthy, and have access to our award-winning Member-to-Member program.

* The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify

Our Plans - Highlights

All of the plans Elderplan offers include:

4 Medical, hospital and prescription drug coverage

4 Ability to choose any Specialist or Dentist, at no extra cost

4 Over-the-counter (OTC) benefit

4 Flex card to cover out-of-pocket expenses for vision, dental and hearing

4 Care Manager to support and guide you as your health care needs evolve

4 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.

4 Our respected Wellness Incentive Program, 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 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 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.

Important information about our plans

• Network: Our plan allows you to see In-Network and Out-of-Network providers based on our expansive benefit offering. Our plan covers services and benefits from any of our Network providers listed in our Provider and Pharmacy Directory. Our plan also includes point-of-service (POS) coverage for certain services and benefits from any Medicare-certified provider who has not opted out of Medicare; the provider must agree to treat you. Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please see the Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

• 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.

• 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 Member Services at 1-800-353-3765 (TTY 711).

– For Elderplan Plus Long-Term Care Plan call 1-877-891-6447(TTY 711).

– Hours are 8 am to 8 pm, 7 days week.

– Or visit Elderplan’s website at elderplan.org

– Or write to: Elderplan

Attn: Member Services

55 Water Street, 46th Floor

New York, NY 10041

Important information about our plans

• Dual Eligibles: Premiums, co-payments, co-insurance and deductibles may vary based on the level of help eligible through New York State Medicaid Program.

– Call New York State HRA Medicaid Helpline at 1-888-692-6116 (TTY 711) between 9 am and 5 pm, Monday through Friday.

– Or visit health.ny.gov/health_care/medicaid/ldss.htm.

– Or contact Elderplan Member Services for assistance.

• 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.

– Call 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.

– Call New York State HRA Medicaid Helpline at 1-888-692-6116 (TTY 711) between 9 am and 5 pm, Monday through Friday.

– Call New York’s State Pharmaceutical Assistance Program (EPIC) 1-800-332-3742, from 8:30 am to 5 pm, Monday through Friday, (TTY 1-800-290-9138). health.ny.gov/health_care/epic/

Prescription Drug Payment Stages

Up to

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 $545 in 2024.

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-payments or co-insurance for your drugs after you have met your deductible.

Your plan pays its share for covered drug(s) and you pay your share of the cost.

You stay in this stage until the total cost of drugs paid by both you and the plan reaches $5,030.

STAGE 3: COVERAGE GAP STAGE

You pay 25% co-insurance 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 $8,000 on your drug costs.

STAGE 4: CATASTROPHIC STAGE

During this payment stage, the plan pays the full cost for your covered Part D drugs. You pay nothing.

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 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.

• Medicare Part D Drug Plan is your primary drug coverage. EPIC provides secondary coverage for Medicare Part D and EPIC covered drugs after the Part D deductible, if any, is met.

• EPIC pays the Medicare Part D monthly 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 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

• Medicare Part D Drug Plan is your primary drug coverage. EPIC provides secondary coverage for Medicare Part D and EPIC covered drugs after the Part D deductible, if any, is met.

• Deductible Plan Members must pay their Medicare Part D plan premiums each month.

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

• 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.

NY State Pharmaceutical Assistance Program

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

NY State Pharmaceutical Assistance Program

Income

For purposes of your EPIC enrollment, household gross income is the previous year’s total annual income for the member or married spouse. 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

Income does not include:

• Food stamps

• Medicare premiums

• Medicaid

• Scholarships

• Grants

• Surplus food

• Payments made to veterans under the federal Veterans’ Dioxin and Radiation Exposure Compensations Standards Act (Agent Orange)

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

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.

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 $0.10 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, 2019. She doesn’t have prescription drug coverage from any other source. She didn’t join a Medicare drug plan by July 31, 2019, and instead joined during the Open Enrollment Period that ended December 7, 2021. Her drug coverage started January 1, 2022.

Since Mrs. Martinez was without creditable prescription drug coverage from August 2019 – December 2021, her penalty in 2023 is 29% (1% for each of the 29 months) of $32.74 (the national base beneficiary premium for 2023) or $9.49 each month. Since the monthly penalty is always rounded to the nearest $0.10, she will pay $9.50 each month in addition to her plan’s monthly premium.

Here’s the math:

• .29 (29% penalty) × $32.74 (2023 base beneficiary premium) = $9.49

• $9.49 rounded to the nearest $0.10 = $9.50

• $9.50 = Mrs. Martinez’s monthly late enrollment penalty for 2023

When Can You Enroll?

Initial Coverage Enrollment Period (ICEP)

Varies by your birthday or month you meet Medicare eligibility requirements

7 month period that starts 3 months before and ends 3 months after the month of your 65th birthday or month you meets Medicare eligibility requirements.

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

During AEP, you can change your Medicare health plans and prescription drug coverage for the following year to better meet your needs. Enrollment will become effective 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 Medicare Advantage plan and switch to a different Medicare Advantage plan one time only during this period. You can also return to original Medicare and add or drop Part D coverage.

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 Coverage (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

Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)

A health plan designed specifically for Medicare beneficiaries who also have Medicaid that offers medical, hospital, and prescription drug coverage—all in one simple plan. Plus, extra benefits like the ability to see any dentist or specialist at no extra cost, a new expanded over-the-counter (OTC)*, a Flex spending card, and a dedicated care manager who will be there to support and guide you by helping to coordinate your benefits, answer your questions and more.

Members of this plan will also be able to participate in our Wellness Incentive Program that rewards you for receiving eligible screenings and vaccinations, receive a gym membership to help you stay healthy, and have access to our award-winning Member-to-Member program.

*The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify

Elderplan For Medicaid Beneficiaries (HMO-POS 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, traditional OTC plus now including payments toward rent/mortgage plus utilities, internet, groceries, home-delivered meals.*

The plan includes comprehensive dental, $500 annual allowance for Flex Cards to help with out-of-pocket expenses on dental, vision and hearing, transportation to and from medical appointments, worldwide emergency coverage, and a memory fitness program that uses games and puzzles to improve brain function with BrainHQ®.

*The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify

Elderplan For Medicaid Beneficiaries (HMO-POS 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, co-insurance, and co-payments). These individuals are also eligible for full Medicaid benefits.

• Qualified Medicare Beneficiary (QMB & QMB+): Helps pay Medicare Part A and Part B premiums, and other cost-sharing (like deductibles, co-insurance, and co-payments). (Some people with QMB are also eligible for full Medicaid benefits (QMB+).)

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

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

Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)

BENEFIT YOU PAY

Part B Deductible $0 or $226^

Primary Care Provider (PCP) Visits

In Network: $0* or 20% co-insurance for in-person visits and telehealth services

Specialists Visits

In-Network and Out-of-Network: $0* or 20% co-insurance for each office visit

Telehealth services available for in-network specialists only. No referral needed to see in or out-of-network specialists.

Lab Services/Outpatient Blood Services

$0 co-payment for each service

Diagnostic Tests and Procedures

$0* or 20% co-insurance for each service

$0* or 20% co-insurance for each service

Diagnostic Radiological Services

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

Therapeutic Radiology Services

$0* or 20% co-insurance for each service

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

^These are 2023 cost-sharing amounts and may change for 2024. Elderplan for Medicaid Beneficiaries (HMO-POS D-SNP) will provide updated rates at www.elderplan.org as soon as they are released.

Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)

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 $33.90 per month

$0^ or $545

Depending on your level “Extra Help” You Pay: $0 co-payment or $1.55 co-payment or $4.50 co-payment or 25% of the cost

Initial Coverage Stage (30-day supply)† For all Other Drugs

Depending on your level “Extra Help” You Pay: $0 co-payment or $4.60 co-payment or $11.20 co-payment 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.

†One-month supply for Standard retail (in-network), Long-term care (31-day), and Out-of-network cost-share.

*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-POS D-SNP)

BENEFIT YOU PAY

For each benefit period^:

$0* or $1,600 deductible.

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

Inpatient Hospital Stays

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

Days 91 and beyond: $800 co-payment per lifetime reserve day.

Beyond lifetime reserve days: you pay all costs.

Authorization is required.

Emergency Care

Urgent Care

Worldwide Emergency / Emergency Transportation / Urgent Coverage

$0* or 20% co-insurance (up to $90) for each visit. If admitted to the hospital within 24 hours for the same condition, cost sharing is waived.

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

$0 co-payment for Worldwide Emergency / Emergency Transportation / Urgent Coverage. The maximum benefit coverage amount is $50,000.

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

^These are 2023 cost-sharing amounts and may change for 2024. Elderplan for Medicaid Beneficiaries (HMO-POS D-SNP) will provide updated rates at www.elderplan.org as soon as they are released.

Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)

BENEFIT YOU GET

Over-the-Counter (OTC) Benefit

+ Special Supplemental Benefit for the Chronically Ill (SSBCI) Benefit

Receive $210 every month toward traditional eligible OTC items. Any OTC card balance cannot be carried over to the next month.

For eligible members (with certain chronic conditions) the SSBCI benefit combines with OTC benefit to include payments toward rent/mortgage, utilities, internet, certain grocery items, and meals as a part of the OTC allowance. Eligible members will be notified and provided instructions on how to access this benefit.

Fitness Benefit

$0 co-payment.

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

Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)

BENEFIT YOU PAY

Diagnostic Hearing Exams

$0* or 20% co-insurance for each Medicare-covered diagnostic hearing exam.

Routine Hearing Exam

$0 co-payment for one Routine (non-Medicare-covered) hearing exam every 3 years.

Up to $1,300 maximum benefit for both ears combined, every 3 years.

$0 co-payment for Fitting/Evaluation for Hearing Aid every 3 years.

Hearing Aids

Authorization required for hearing aid(s) by a Physician or Specialist.

You may also use your Flex card allowance toward out-of-pocket expenses in excess of the above.

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

Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)

BENEFIT YOU PAY

Diagnostic Vision Exam

$0* or 20% co-insurance for each Medicare-covered eye exam.

Routine Vision Exam

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

Vision Eyewear

$0 co-payment for Routine (non-Medicare-covered) eyewear up to $350 annual maximum per year including contact lenses and eyeglasses (lenses and frames).

You may also use your Flex card allowance toward out-of-pocket expenses in excess of the above.

Medicare-Covered Eyewear

$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-POS D-SNP)

BENEFIT YOU PAY

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

$0 co-payment for Supplemental Preventive Dental Services limited to selected services codes in-network and out-of-network combined.

(Please refer to Evidence of Coverage for details or call Member Services).

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.

Supplemental Comprehensive Dental Services limited to $1,500 allowance for selected services codes in-network and  out-of-network combined. Benefit frequency may be limited per American Dental Association guidelines.

(Please refer to Evidence of Coverage for details or call Member Services).

You may also use your Flex card allowance toward out-of-pocket expenses in excess of the above.

Comprehensive Dental (Medicare-covered)

$0* or 20% co-insurance for Medicare-covered comprehensive dental services.

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

Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)

BENEFIT YOU PAY

Diabetic Supplies

$0 co-payment for Medicare-covered Diabetes Supplies. Diabetic Testing Strips and Blood Glucose Meters are limited to certain manufacturers.

Transportation

$0 co-payment for up to 24 one-way trips per year. You may take a Taxi, Bus, Subway, or Van.

Acupuncture (supplemental)

$0 co-payment per visit. You may receive up to 20 visits per year for: Acupuncture, Cupping/Moxa, Acupressure, Tui Na, Gua Sha, Reflexology, Infrared Therapy.

Flex Card

Podiatry (supplemental)

You will receive a $500 allowance to use in 2024 on out-of-pocket costs for dental, vision and hearing. Any unused benefit dollars will expire at the end of the calendar year 2024 or if you disenroll from the plan.

In-Network:

$0 co-payment each visit. You may receive up to 12 Routine Foot Care visits per year.

Out-of-Network:

$0 co-payment each visit. You may receive up to 12 Routine Foot Care visits per year.

Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)

BENEFIT YOU PAY

In-Network: $0* or 20% co-insurance for each visit.

Physical Therapy / Occupational Therapy / Speech Therapy

Out-of-Network: $0* or 20% co-insurance for each visit.

Authorization is required.

Mental Health / Psychiatry

In-Network: $0* or 20% co-insurance for each individual or group in-office or telehealth session.

Out-of-Network: $0* or 20% co-insurance for each individual or group session.

Maximum Out of Pocket (MOOP) $8,850 In-Network and Out-of-Network combined.

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

Why choose Elderplan for Medicaid Beneficiaries (HMO-POS D-SNP)?

Recap of a few plan highlights:

4 Between Elderplan Medicare Advantage and State Medicaid, you may not pay for your medical services^

4 Low co-payments for prescription drugs

4 Access to Board-certified private practice PCPs and Specialists

4 Flexibility to see any specialist or dentist, at no extra cost

4 $2,520 a year toward over the counter (OTC) health-related, select healthy grocery items, meals, internet, wireless, utility bill pay and rental/mortgage assistance*

4 Flex Card with $500 annual allowance to be used for out-of-pocket expenses for hearing, vision and dental

4 Worldwide Emergency coverage up to $50,000

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

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

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

*The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify. Unused OTC card balance cannot be carried over from month to month.

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

Q&A / Final Summary of Benefits Review

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 one of our many in-network Primary Care Providers but can use any Specialist you want at no extra cost.

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 Drugs, Premiums, and costs.

We would be happy to help you find out if you qualify or you can call one of the numbers below:

Center for Medicare and Medicaid Services (CMS)

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

www.Medicare.gov

1-800-772-1213,

Social Security Administration

1-888-692-6116

8 am to 7 pm, Monday through Friday. www.ssa.gov New York State HRA Medicaid Helpline

9 am to 5 pm, Monday through Friday. (TTY 711)

www.health.ny.gov/health_care/medicaid/ldss.htm

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

A health plan designed specifically for Medicare and Medicaid beneficiaries who need long-term care at home and want their long-term care services, medical, hospital, and prescription drug coverage all together in one simple plan. You will have the ability to see any dentist or specialist at no extra cost, receive a new expanded over-the-counter (OTC)*, a Flex spending card, and be assigned a dedicated care manager who will be there to support and guide you by helping to coordinate your benefits, answer your questions and more.

Members of this plan will also be able to participate in our Wellness Incentive Program that rewards you for receiving eligible screenings and vaccinations, receive a gym membership to help you stay healthy, and have access to our award-winning Member-to-Member program.

*The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify

Elderplan Plus Long-Term Care (HMO-POS 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.

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, now including rent/mortgage plus utilities, internet, groceries, home-delivered meals and traditional OTC*.

The plan includes comprehensive dental, $500 annual allowance for Flex Cards to help with out-of-pocket expenses on dental, vision and hearing, transportation to and from medical appointments, worldwide emergency coverage, and a memory fitness program that uses games and puzzles to improve brain function through BrainHQ®.

We also offer an 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.

*The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify

Elderplan Plus Long-Term Care (HMO-POS 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.

Enrollees 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-POS D-SNP)

BENEFIT YOU PAY

$0 per month

Part D Premium is $48.70 per month

Because you are a dual-eligible member with full Medicaid benefits, your plan premium is covered on your behalf.

Primary Care Provider (PCP) Visits

In Network: $0 co-payment for each visit for in-person visits and telehealth services

In-Network and Out-of-Network:

$0 co-payment for each office visit

Specialist Visits

Lab Services/Outpatient Blood Services

Diagnostic Tests and Procedures

Telehealth services available for in-network specialists only.

No referral needed to see in or out-of-network specialists.

$0 co-payment for each service

$0 co-payment for each service

$0 co-payment for each service

Diagnostic Radiological Services

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

Therapeutic Radiological Services $0 co-payment for each service

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

BENEFIT YOU PAY

$0

Part D Premium is $48.70 per month

Because you are a dual-eligible member with full Medicaid benefits, your plan premium is covered on your behalf.

$0

Part D Deductible is $545 per month

Because you are a dual-eligible member with full Medicaid benefits, your Part D Deductible is covered on your behalf.

Initial Coverage Stage (30-day supply)†

Generic Drugs

(including brand drugs treated as generic)

Depending on your level of “Extra Help” You Pay: $0 co-payment or $1.55 co-payment or $4.50 co-payment 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-payment or $4.60 co-payment or $11.20 co-payment 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.

† One-month supply for Standard retail (in-network), Long-term care (31-day), and Out-of-network cost-share.

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

BENEFIT YOU PAY

$0 co-payment for each benefit period.

Inpatient Hospital Stays

$0 co-payment per day.

Authorization is required.

$0 co-payment for each visit

Emergency Care

Urgent Care

Worldwide Emergency / Emergency Transportation / Urgent Coverage.

If admitted to the hospital within 24 hours for the same condition, cost sharing is waived.

$0 co-payment for each visit

$0 co-payment for Worldwide Emergency / Emergency Transportation / Urgent Coverage. The maximum benefit coverage amount is $50,000.

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

BENEFIT

Over-the-Counter (OTC) Benefit

+ Special Supplemental Benefit for the Chronically Ill (SSBCI) Benefit

YOU RECEIVE

$270 every month toward traditional eligible OTC items. Any OTC card balance cannot be carried over to the next month.

For eligible members (with certain chronic conditions) the SSBCI benefit combines with OTC benefit to include payments toward rent/mortgage, utilities, internet, certain grocery items, and meals as a part of the OTC allowance. Eligible members will be notified and provided instructions on how to access this benefit.

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

BENEFIT YOU PAY

Diagnostic Hearing Exam

$0 co-payment for each Medicare-covered diagnostic hearing exam.

Hearing Services

$0 co-payment for each Medicaid-covered hearing services.

Up to $1,300 maximum benefit for both ears combined, every 3 years. 1-year supply of batteries included with the purchase and will be shipped with the hearing aid.

Hearing Aids

$0 co-payment for Fitting/Evaluation for Hearing Aid every 3 years.

Authorization required for hearing aid(s) by a Physician or Specialist.

You may also use your Flex card allowance toward out-of-pocket expenses in excess of the above.

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

BENEFIT YOU PAY

Diagnostic Vision Exam

$0 co-payment for each Medicare-covered eye exam.

Medicare-Covered Eyewear

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

Vision Eyewear

$0 co-payment for (Medicaid-covered) eyewear up to $350 annual maximum per year including contact lenses and eyeglasses (lenses and frames).

You may also use your Flex card allowance toward out-of-pocket expenses in excess of the above.

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

BENEFIT YOU PAY

Supplemental Preventive Dental

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

$0 co-payment for Supplemental Preventive Dental Services limited to selected services codes in-network and out-of-network combined.

(Please refer to Evidence of Coverage for details or call Member Services).

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.

$0 co-payment for Supplemental Comprehensive Dental Services limited to selected services codes in-network and out-of-network combined. Benefit frequency may be limited per American Dental Association guidelines.

(Please refer to Evidence of Coverage for details or call Member Services).

You may also use your Flex card allowance toward out-of-pocket expenses in excess of the above.

Comprehensive Dental (Medicare-covered)

$0 co-payment for Medicare-covered comprehensive dental services.

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

BENEFIT YOU PAY

Personal Care Services

Social and Environmental Support

Personal Emergency Response Services

$0 co-payment

$0 co-payment

$0 co-payment

Diabetic Supplies

Diabetes Monitoring

Home Health Care

Acupuncture (supplemental)

$0 co-payment for Medicare-covered services and supplies.

Testing strips limited to certain manufacturers.

$0 co-payment for Medicaid-covered services and supplies.

$0 co-payment

Authorization is required

$0 co-payment per visit. You may receive up to 28 visits per year for: Acupuncture, Cupping/Moxa, Acupressure, Tui Na, Gua Sha, Reflexology, Infrared Therapy.

In-Network:

$0 co-payment each visit. You may receive up to 12

Podiatry (supplemental)

Routine Foot Care visits per year.

Out-of-Network:

$0 co-payment each visit. You may receive up to 12 Routine Foot Care visits per year.

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

BENEFIT YOU PAY

Flex Card

Physical Therapy / Occupational Therapy / Speech Therapy

You will receive a $500 allowance to use in 2024 on out-of-pocket costs for dental, vision and hearing. Any unused benefit dollars will expire at the end of the calendar year 2024 or if you disenroll from the plan.

In-Network:

$0 co-payment for each visit.

Out-of-Network:

$0 co-payment for each visit.

Authorization is required.

Maximum Out of Pocket (MOOP)

$0 co-payment

$8,850 In-Network and Out-of-Network combined.

Why choose Elderplan Plus Long-Term Care (HMO-POS D-SNP)?

Recap of a few plan highlights:

4 Between Elderplan Medicare Advantage and State Medicaid, you may not pay for your medical services^

4 Low co-payments for prescription drugs

4 Access to Board-certified private practice PCPs and Specialists

4 Flexibility to see any specialist or dentist, at no extra cost

4 $3,240 a year toward over the counter (OTC) health-related, select healthy grocery items, meals, internet, wireless, utility bill pay and rental/mortgage assistance*

4 Flex Card with $500 annual allowance to be used for out-of-pocket expenses for hearing, vision and dental

4 Worldwide Emergency coverage up to $50,000

4 Transportation to and from medical appointments

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

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

*The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify. Unused OTC card balance cannot be carried over from month to month.

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

Q&A / Final Summary of Benefits Review

Ready to join the Elderplan Family?

We just need to complete your enrollment application and you’re all set!

Choose your PCP.

4 Remember you must use one of our many in-network Primary Care Providers but can use any Specialist you want at no extra cost.

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 Drugs, Premiums, and costs.

We would be happy to help you find out if you qualify or you can call one of the numbers below:

Center for Medicare and Medicaid Services (CMS)

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

www.Medicare.gov

1-800-772-1213,

Social Security Administration

1-888-692-6116

8 am to 7 pm, Monday through Friday. www.ssa.gov New York State HRA Medicaid Helpline

9 am to 5 pm, Monday through Friday. (TTY 711)

www.health.ny.gov/health_care/medicaid/ldss.htm

Elderplan Flex (HMO-POS)

A health plan designed specifically for Medicare beneficiaries that offers the flexibility to choose the benefits and doctors you want. In addition to offering medical, hospital, and prescription drug coverage, this plan also allows you to pick between an over-the-counter (OTC)* benefit that you can use toward traditional OTC items, groceries, and home-delivered meals, OR transportation to and from medical appointments. You can even see any specialist or dentist at no extra cost and have a dedicated care management team that will be there to support and guide you by helping to coordinate your benefits, answer your questions, and more.

Members of this plan will also be able to participate in our Wellness Incentive Program that rewards you for receiving eligible screenings and vaccinations, receive a gym membership to help you stay healthy, and have access to our award-winning Member-to-Member program.

*The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify

Elderplan Flex (HMO-POS)

A plan designed for Medicare beneficiaries that gives you the care you need and the choices you want. Elderplan Flex offers a $0 Premium, low copayments, and no referrals to see your doctor, plus ability to see any specialist or dentist you want at no extra cost. 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 Select Extras. Elderplan’s Flex Select Extras give you the option of selecting OTC coverage, which you can use to pay for healthrelated, select grocery items at a store or order online, as well as home-delivered meals*, OR Transportation to and from medical appointments.

The plan includes comprehensive dental, $500 annual allowance for Flex Cards to help with out-of-pocket expenses on dental, vision and hearing, worldwide emergency coverage, gym membership, a memory fitness program that uses games and puzzles to improve brain function through BrainHQ.®

*The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify

Elderplan Flex (HMO-POS)

Part D Premium

Primary Care Provider (PCP) Visits

$0

In-Network: $0 co-payment for in-person visits and telehealth services

In-Network and Out-of-Network:

$35 co-payment for each office visit

$0 co-payment for Endocrinology visits

Specialist Visits

Lab Services/Outpatient Blood Services

Diagnostic Tests and Procedures

Outpatient X-Rays

$10 co-payment for in-network telehealth services (Telehealth services not covered for out-of-network specialists)

No referral needed to see in or out-of-network specialists

$0 co-payment for each service

$35 co-payment for each service

$20 co-payment for each service

20% co-insurance for each service

Diagnostic Radiological Services

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

Elderplan Flex (HMO-POS)

BENEFIT YOU RECEIVE

Flex Card

You will receive a $500 allowance to use in 2024 on out-of-pocket costs for dental, vision and hearing. Any unused benefit dollars will expire at the end of the calendar year 2024 or if you disenroll from the plan.

Elderplan Flex (HMO-POS)

BENEFIT YOU PAY

Over-the-Counter (OTC) Benefit

+ Special Supplemental Benefit for the Chronically Ill (SSBCI) Benefit

Receive $140 every quarter toward traditional eligible OTC items. Any OTC card balance cannot be carried over to the next quarter.

For eligible members (with certain chronic conditions) the SSBCI benefit combines with 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 this benefit.

OR

Transportation Benefit

$0 co-payment for up to 48 one-way trips per year. You may take a Taxi, Bus, Subway, or Van.

Elderplan Flex (HMO-POS)

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.

The deductible only applies to drugs in Tiers 4 & 5. Members pay the full cost of their drugs until their $545 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

Elderplan Flex (HMO-POS)

BENEFIT YOU PAY

You pay per admission:

Inpatient Hospital Stays

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

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

Authorization is required.

$90 co-payment for each visit.

Emergency Care

If admitted to the hospital within 24 hours for the same condition, co-payment is waived.

Urgent Care

Worldwide Emergency / Emergency

Transportation / Urgent Coverage.

$35 co-payment for each office visit.

$10 co-payment for telehealth services.

$0 co-payment for Worldwide Emergency / Emergency

Transportation / Urgent Coverage. The maximum benefit coverage amount is $50,000.

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

Ambulance

Authorization is required for non-emergency services.

Elderplan Flex (HMO-POS)

BENEFIT YOU PAY

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

$0 co-payment for Supplemental Preventive Dental Services limited to selected services codes in-network and out-of-network combined.

(Please refer to Evidence of Coverage for details or call Member Services).

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.

Supplemental Comprehensive Dental Services limited to $1,500 allowance for selected services codes in-network and out-of-network combined. Benefit frequency may be limited per American Dental Association guidelines. (Please refer to Evidence of Coverage for details or call Member Services).

You may also use your Flex card allowance toward out-of-pocket expenses in excess of the above.

Comprehensive Dental (Medicare-covered)

20% co-insurance for Medicare-covered comprehensive dental services.

Elderplan Flex (HMO-POS)

BENEFIT YOU PAY

Diagnostic Hearing Exam

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

Routine Hearing Exam

Hearing Aids

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

Up to $1,000 maximum benefit every year for both ears combined ($500 will be available per ear). $0 co-payment for Fitting/Evaluation for Hearing Aid every year.

Authorization required for hearing aid(s) by a Physician or Specialist.

You may also use your Flex card allowance toward out-of-pocket expenses in excess of the above.

Elderplan Flex (HMO-POS)

BENEFIT YOU PAY

Diagnostic Vision Exam

$25 co-payment for Medicare-covered eye exam

Routine Vision Exam

Vision Eyewear

Supplemental Routine Eyewear

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

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

$0 co-payment for Routine (non-Medicare-covered) eyewear up to $250 annual maximum per year including contact lenses and eyeglasses (lenses and frames).

You may also use your Flex card allowance toward out-of-pocket expenses in excess of the above.

Elderplan Flex (HMO-POS)

BENEFIT YOU PAY

Preventive Services

$0 co-payment

Diabetic Supplies

$0 co-payment for Medicare-covered Diabetes Supplies.

Diabetic Testing Strips and Blood Glucose Meters are limited to certain manufacturers.

Therapeutic Radiology Services

20% co-insurance for each service

Fitness Benefit

Acupuncture (supplemental)

$0 co-payment.

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

$0 co-payment per visit. You may receive up to 20 visits per year for: Acupuncture, Cupping/Moxa, Acupressure, Tui Na, Gua Sha, Reflexology, Infrared Therapy.

Why Choose Elderplan Flex (HMO)?

Recap of a few plan highlights:

4 $0 Monthly Plan Premium

4 Low-cost sharing on prescription drugs (depending on LIS level)

4 $0 co-payment for your in-network PCP, including telehealth services

4 Flexibility to see any Specialist or Dentist, at no extra cost

4 Access to Board-certified private practice PCPs and Specialists

4 Freedom to choose benefits that are important to you with Elderplan Flex Select Extras

4 There are no referrals necessary for both in and out-of-network specialists

4 Comprehensive Dental coverage

4 Flex Card with $500 annual allowance to be used for out-of-pocket expenses for hearing, vision and dental

4 $560 a year for OTC health related items, as well as select grocery items and meals if eligible*^

4 Worldwide Emergency coverage up to $50,000

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

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

4 Access to our award-winning Member-to-Member Program

^Unused OTC card balance cannot be carried over from quarter to quarter.

*The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify.

Q&A / Final Summary of Benefits review

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 one of our many in-network Primary Care Providers but can use any Specialist you want at no extra cost.

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 Drugs, Premiums, and costs.

We would be happy to help you find out if you qualify or you can call one of the numbers below:

Center for Medicare and Medicaid Services (CMS)

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

www.Medicare.gov

1-800-772-1213,

Social Security Administration

1-888-692-6116

8 am to 7 pm, Monday through Friday. www.ssa.gov New York State HRA Medicaid Helpline

9 am to 5 pm, Monday through Friday. (TTY 711)

www.health.ny.gov/health_care/medicaid/ldss.htm

Elderplan Extra Help (HMO-POS)

A health plan designed specifically for Medicare beneficiaries who are eligible for Extra Help. This plan offers medical, hospital, and prescription drug coverage at little-or-no premium and low copays. Plus, extra benefits like the ability to see any Dentist or Specialist at no extra cost, a new expanded OTC*, a Flex Card allowance, and a dedicated Care Management Team that will be there to support and guide you by helping to coordinate your benefits, answer your questions and more.

Members of this plan will also be able to participate in our Wellness Incentive Program that rewards you for receiving eligible screenings and vaccinations, receive a gym membership to help you stay healthy, and have access to our award-winning Member-to-Member Program.

*The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify

Elderplan Extra Help (HMO-POS)

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 or no premium and low co-payments. In addition to medical and hospital coverage, our members with Low Income Subsidy (LIS) will also benefit from 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 includes comprehensive dental, Flex Card with $500 annual allowance to help with out-of-pocket expenses on dental, vision and hearing, worldwide emergency coverage, gym membership, a memory fitness program that uses games and puzzles to improve brain function through BrainHQ®.

^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.

*The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify

Elderplan Extra Help (HMO-POS)

BENEFIT YOU PAY

Part D Premium

Primary Care Provider (PCP) Visits

$34.70 monthly plan premium*

In-Network: $0 co-payment for in-person visits and telehealth services

In-Network and Out-of-Network:

$25 co-payment for each office visit

$0 co-payment for Endocrinology visits

Specialist Visits

Lab Services/Outpatient Blood Services

Diagnostic Tests and Procedures

Outpatient X-Rays

$10 co-payment for in-network telehealth services

(Telehealth services not covered for out-of-network specialists)

No referral needed to see in or out-of-network specialists

$0 co-payment for each service

$35 co-payment for each service

$20 co-payment for each service

20% co-insurance for each service

Diagnostic Radiological Services

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

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

Elderplan Extra Help (HMO-POS)

BENEFIT YOU PAY

Over-the-Counter (OTC) Benefit

+ Special Supplemental Benefit for the Chronically Ill (SSBCI) Benefit

$140 every quarter toward traditional eligible OTC items. Any OTC card balance cannot be carried over to the next quarter.

For eligible members (with certain chronic conditions) the SSBCI benefit combines with 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 this benefit.

Flex Card

Acupuncture (supplemental)

You will receive a $500 allowance to use in 2024 on out-of-pocket costs for dental, vision and hearing. Any unused benefit dollars will expire at the end of the calendar year 2024 or if you disenroll from the plan.

$0 co-payment per visit. You may receive up to 20 visits per year for: Acupuncture, Cupping/Moxa, Acupressure, Tui Na, Gua Sha, Reflexology, Infrared Therapy.

Transportation

$0 co-payment for up to 32 one-way trips per year. You may take a Taxi, Bus, Subway, or Van.

Elderplan Extra Help (HMO-POS)

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.

The deductible only applies to drugs in Tiers 4 & 5. Members pay the full cost of their drugs until their $545 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

Elderplan Extra Help (HMO-POS)

BENEFIT YOU PAY

You pay per admission:

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

Inpatient Hospital Stays

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

Authorization is required

$90 co-payment for each visit

Emergency Care

Urgent Care

Worldwide Emergency / Emergency Transportation / Urgent Coverage

If admitted to the hospital within 24 hours for the same condition, co-payment is waived

$35 co-payment per office visit

$10 co-payment for telehealth services

$0 co-payment for Worldwide Emergency / Emergency Transportation / Urgent Coverage. The maximum benefit coverage amount is $50,000.

$215 co-payment for each one-way trip

Ambulance

Authorization is required for non-emergency services

Elderplan Extra Help (HMO-POS)

BENEFIT YOU PAY

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

$0 co-payment for Supplemental Preventive Dental Services limited to selected service codes in-network and out-of-network combined.

(Please refer to Evidence of Coverage for details or call Member Services).

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.

Supplemental Comprehensive Dental Services limited to selected service codes in-network and out-of-network combined. Benefit frequency may be limited per American Dental Association guidelines.

(Please refer to Evidence of Coverage for details or call Member Services).

You may also use your Flex card allowance toward out-of-pocket expenses in excess of the above.

Comprehensive Dental (Medicare-covered)

20% co-insurance for Medicare-covered comprehensive dental services.

Elderplan Extra Help (HMO-POS)

BENEFIT YOU PAY

Diagnostic Hearing Exam

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

Routine Hearing Exam

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

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

$0 co-payment for Fitting/Evaluation for Hearing Aid every 3 years for one ear.

Hearing Aids

Authorization required for hearing aid(s) by a Physician or Specialist. You may also use your Flex card allowance toward out-of-pocket expenses in excess of the above.

Diagnostic Vision Exam

Routine Vision Exam

Vision Eyewear

$25 co-payment for each Medicare-covered eye exam

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

$0 co-payment 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).

You may also use your Flex card allowance toward out-of-pocket expenses in excess of the above.

Elderplan Extra Help (HMO-POS)

BENEFIT YOU PAY

Preventive Services

$0 co-payment

Diabetic Supplies

$0 co-payment for Medicare-covered Diabetes Supplies. Diabetic Testing Strips and Blood Glucose Meters are limited to certain manufacturers.

Therapeutic Radiology Services

20% co-insurance for each service

Fitness Benefit

$0 co-payment.

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

Why choose Elderplan Extra Help (HMO)?

Recap of a few plan highlights:

4 Low-cost sharing on prescription drugs (depending on LIS level)

4 $0 co-payment for your in-network PCP, including telehealth services

4 Flexibility to see any Specialist or Dentist, at no extra cost

4 Access to Board-certified private practice PCPs and Specialists

4 There are no referrals necessary for both in and out-of-network specialists

4 Comprehensive Dental coverage

4 Flex Card with $500 annual allowance to be used for out-of-pocket expenses for hearing, vision and dental

4 $560 a year for OTC health related items, as well as select grocery items and meals if eligible*^

4 Worldwide Emergency coverage up to $50,000

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

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

4 Access to our award-winning Member-to-Member Program

^Unused OTC card balance cannot be carried over from quarter to quarter.

*The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify.

Q&A / Final Summary of Benefits review

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 one of our many in-network Primary Care Providers but can use any Specialist you want at no extra cost.

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 Drugs, Premiums, and costs.

We would be happy to help you find out if you qualify or you can call one of the numbers below:

What are the beneficiary’s Part D financial responsibilities with Elderplan for 2024?