2021 015 Pre-Enrollment Kit

2021

Pre-Enrollment Kit Elderplan Assist (HMO IE-SNP) January 1, 2021 to December 31, 2021

Table of Contents Plan Information

SECTION 1

Ways to Enroll........................................................................... 5

Pre-Enrollment Checklist.................................................... 44

Summary of Benefits.............................................................. 7

Plan Ratings............................................................................. 47

Ready to Enroll Now?

SECTION 2

Attestation of Eligibility.......................................................51

Authorization for Access to Patient Information . .......67

Enrollment Form.....................................................................55

Notice of Privacy Practices.................................................69

What’s Next What to Expect?.....................................................................77

SECTION 3 Health Care Proxy Form.......................................................85

Make Your Health Care Wishes Known...........................78

Benefit Advisor Tools Scope of Appointment......................................................... 91 Translator/Witness Form.................................................... 93

SECTION 4 Checklist................................................................................... 95

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SECTION 1

Plan Information

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Thank you for your interest in Elderplan!

This book includes the plan information you requested along with all of the necessary forms and ways you can enroll.

If you are ready to enroll, please follow these simple steps:

STEP 1: DETERMINE IF YOU ARE ELIGIBLE

P Are you entitled to Medicare Parts A and B? P Do you live in Queens, Brooklyn, Staten Island, Manhattan, the Bronx, Westchester, Rockland, Putnam, Dutchess, Orange, or Monroe County at least six months out of the year?

Additional eligibility criteria apply for Special Needs Plans (SNP) — see Summary of Benefits for details.

If you answered YES to these questions, you are eligible to enroll with Elderplan.

STEP 2: JOIN THE ELDERPLAN FAMILY! It’s easy as 1-2-3 and there are four convenient ways for you to enroll! oing to our website: G Visit Elderplan.org, Click on “Enroll Now.” You will be prompted to fill out the appropriate forms. alling us: C Prefer to enroll with us over the phone? If you don’t have much time or just prefer to talk on the phone, one of our Benefit Advisors will be happy to assist in your enrollment. We can also arrange for a Benefit Advisor to come to your home at a time that’s convenient for you.

S imply call us at 1-866-694-3090 (TTY 711 for the hearing impaired) 8 a.m. – 8 p.m., 7 days a week to schedule an appointment. isiting our office: V Prefer to come to us? Visit our office located at 6405 Seventh Avenue, Brooklyn, NY 11220.

No appointment necessary. Monday thru Friday 9 a.m. to 5 p.m.

Mailing the forms: Fill out the forms listed on the next page and provided in this book. Mail them in to us in the pre-addressed and stamped envelope provided in the back of the book.

STEP 3: REVIEW AND VERIFY To ensure your enrollment goes smoothly make sure to include the forms listed on the next page and make sure that everything has been filled out completely.

H3347_EP16149_Accepted

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FORMS THAT NEED TO BE RETURNED: Form 1: Attestation of Eligibility (page 51) Form 2: Elderplan Enrollment Form (page 55) Form 3: Authorization for Access to Patient Information (page 67) It is important that the following fields on the enrollment form are completed: • All your personal information: First and last name, address, date of birth and telephone number. Please print your name as it appears on your Medicare card.

• Medicare Insurance Information: Copy your Medicare claim number and effective dates from your Medicare card.

• Select a premium payment option, if applicable.

• Choose a Primary Care Physician (PCP) from Elderplan’s network: You can browse current providers by visiting www.elderplan.org and clicking on “Find a Provider” or by calling Members Services. Put your initials on the line provided next to your selection for application to be processed.

• Complete the questions within the enrollment form.

• Sign and date the last page of the enrollment form. Make sure you read all the benefit information prior to signing.

• Mail it in. Place the application in the postage paid envelope provided.

THAT’S IT! One of the good people at Elderplan will call you to confirm enrollment and answer any questions you may have.

Member Services: 1-800-353-3765 (TTY/TDD 711) 8 a.m.–8 p.m., 7 days a week 6323 Seventh Avenue, Brooklyn NY, 11220 www.elderplan.org 6

2021

Summary of Benefits Elderplan Assist (HMO IE-SNP)

January 1, 2021 to December 31, 2021

H3347_EP16880_M

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Proposed Effective Date _____/_____/_________

Primary Care Provider Name____________________________________________________________________________________ Address__________________________________________________________________________________ Phone Number (_________)____________________________________________________________

Name of Sales Representative ____________________________________________________________________________________________

Important Numbers ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Member Services 1-800-353-3765, TTY 711 8 a.m. to 8 p.m., 7 days a week

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Summary of Benefits for Elderplan Assist (HMO IE-SNP)

January 1, 2021 – December 31, 2021 Bronx, Dutchess, Kings, Monroe, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

About Elderplan Elderplan is a not-for-profit organization founded right here in New York. Our primary objective is ensuring that members of our community receive the care and support they deserve. That’s why we offer 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.

Elderplan is a member of MJHS Health System, a not-for-profit founded by Four Brooklyn Ladies in 1907 based on the core values of compassion, dignity and respect.

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

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Elderplan Assist (HMO IE-SNP)

Plan Overview Elderplan makes it possible for you to continue living in your facility while also getting nursing home level care. A skilled Nurse Practitioner (NP) or Physician Assistant (PA), along with a dedicated Registered Nurse (RN) will work together to deliver the quality care you need to remain safely at home. They will coordinate with physicians to create a customized treatment plan, conduct preventive wellnessfocused care, manage chronic

conditions, order lab tests and write prescriptions. They will communicate any updates with you, your doctors, and family members providing comfort and peace of mind.

This added level of care makes it possible for you to remain in your home, and can also help avoid unnecessary and stressful emergency room visits and hospitalizations.

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Contents Section I: Introduction to Summary of Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 • Elderplan Contact Information • Who Can Join?

• Useful Information About Medicare • Information About Elderplan Assist Section II: Summary of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 • Monthly Premium, Deductible, And Maximum Out-Of-Pocket Costs • Medicare-Covered Benefits • Prescription Drug Benefits • Other Covered Benefits

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Benefits at a Glance Part B Deductible Doctor Visits (Primary Care) Specialist Care

$0

Routine Hearing Routine Vision Transportation Acupuncture Routine Podiatry Over-the-Counter (OTC) Benefits

$10 up to

$25 every month

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Section I: Introduction to Summary of Benefits Elderplan is an HMO plan with a Medicare contract. Enrollment in Elderplan depends on contract renewal. Anyone entitled to Medicare Parts A and B may apply. Enrolled members must continue to pay their Medicare part B premium if not otherwise paid for by a third party.

This booklet gives you a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, see the 2021 Elderplan Assist (HMO IE-SNP) Evidence of Coverage. A copy of the Evidence of Coverage is located on our website at www.elderplan.org.

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Elderplan Contact Information Elderplan Assist hours of operation • From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. Eastern Time.

• From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. Eastern Time.

Elderplan Assist phone numbers and website • If you are a member of this plan, call toll-free 1-800-353-3765. (TTY users should call 711.) Hours are 8 a.m. to 8 p.m., 7 days a week.

• If you are not a member of this plan, call toll-free 1-866-695-8101. (TTY users should call 711.) Hours are 8 a.m. to 8 p.m., 7 days a week.

• Our website: www.elderplan.org.

This document is available for free in Spanish. Please contact our Member Services number at 1-800-353-3765 for additional information. (TTY users should call 711.) Hours are 8 a.m. to 8 p.m., 7 days a week. This information is also available in different formats, including Braille or other alternate formats. Please call Member Services at the number listed above if you need plan information in another format or language.

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Who Can Join?

To join Elderplan Assist (HMO IE-SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in a Congregate Care Setting.

(Assisted Living Facility)

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Our service area includes the following counties in New York: Bronx, Dutchess, Kings, Monroe, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester counties.

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Useful Information About Medicare • You can compare Elderplan You have choices about how Assist and Original Medicare to get your Medicare Benefits • One choice is to get your Medicare benefits through Original Medicare (fee‑for‑service Medicare).

Original Medicare is run directly by the Federal Government.

• Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Elderplan Assist (HMO IE‑SNP)).

using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers. Our members receive all of the benefits that Original Medicare offers. The covered benefits may change from year to year.

Tips for Comparing your Medicare Choices This Summary of Benefits booklet gives you a summary of what Elderplan Assist (HMO IE-SNP) covers and what you pay.

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

• If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1‑800‑633-4227), 24 hours a day, 7 days a week.

TTY users should call 1‑877‑486‑2048.

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• If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov.

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Information About Elderplan Assist Special eligibility requirements for our plan • Must have Medicare Part A and Medicare Part B. • Must reside in the plan’s service area: Bronx, Dutchess, Kings, Monroe, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk and Westchester counties.

• Must be a United States citizen or lawfully present in the United States.

• You must live in a Congregate Care Setting of an Assisted Living Facility and require an institutional level of care as determined by the New York State approved assessment.

Please note: If you lose your eligibility but can reasonably be expected to regain eligibility within one (1) month, then you are still eligible for membership in our plan (the Evidence of Coverage Chapter 4, Section 2.1 tells you about coverage and cost sharing during a period of deemed continued eligibility.)

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Which Doctors, Hospitals, and Pharmacies can I use?

What do we cover?

Like all Medicare health plans, Elderplan Assist (HMO IE‑SNP) we cover everything that Original Medicare covers—and more. has a network of doctors, hospitals, pharmacies and • Members get all of the other providers. If you use benefits covered by Original the providers that are not in Medicare. our network, we may not pay • Members also get more than for these services except in what is covered by Original emergency situations, you Medicare. Some of the extra must generally use network benefits are outlined in this pharmacies to fill your booklet. prescriptions for covered • We cover Part D drugs. In Part D drugs. addition, we cover Part B You can see our plan’s drugs such as chemotherapy Provider and Pharmacy and some drugs administered Directory at our website by your provider. www.elderplan.org, or call us You can see the complete and we will send you a copy plan formulary (list of Part D of the Provider and Pharmacy prescription drugs) and any Directory. restrictions on our website, www.elderplan.org, or call us and we will send you a copy of the formulary.

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

How will I determine my drug costs?

The amount you pay for drugs depends on the drug you are taking, what “drug payment stage” you have reached, and the plan cost-sharing tiers.

Later in this document we discuss the drug payment stages and the plan cost‑sharing tiers. The drug payment stages are the Deductible Stage, Initial Coverage Stage, Coverage Gap and Catastrophic Coverage Stage. Every drug on the plan’s Drug List is in one of five cost-sharing tiers:

•T ier 1: Preferred Generic Drugs (lowest cost-sharing tier) •T ier 2: Generic Drugs •T ier 3: Preferred Brand Drugs •T ier 4: Non-preferred Drugs • Tier 5: Specialty Tier Drugs (highest cost-sharing tier) There are programs to help people with limited resources pay for their drugs.

These include “Extra Help” and State Pharmaceutical Assistance Programs. For more information, see the Evidence of Coverage (Chapter 2, Section 7).

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Section II: Summary of Benefits The following are the health care costs for Elderplan Assist.

Elderplan Assist (HMO IE-SNP) Monthly Premium (Part D Premium)

$42.30

Part B Deductible

$0

Maxiumum Out‑of‑Pocket

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$7,550

In addition, you must keep paying your Medicare Part B premium.

Like all Medicare health plans, our plan protects you by having yearly limits on your out‑of‑pocket costs for medical and hospital care.

If you reach the limit on out‑of‑pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your plan premium and any cost-sharing for your Part D prescription drugs.

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare-covered Benefits Health Need Covered or Problem Benefit

What You Should Know

Inpatient Hospital Services

You pay per admission: Days 1–6: Authorization is $320 copayment required. each day Day 7 and beyond: $0 copayment each day

Outpatient Hospital Services

$250 copayment.

Ambulatory Surgical Center (ASC)

$100 copayment.

You need hospital care

You want to see a doctor

Your Cost Share

Primary Care Providers

$0 copayment for each visit.

This benefit is also available through Telehealth.

Please call your current provider for details.

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare-covered Benefits Health Need Covered or Problem Benefit

You want to see a doctor (continued)

Your Cost Share

What You Should Know

Specialists

$0 copayment for each visit.

This benefit is also available through Telehealth.

Please call your current provider for details.

Nurse Practioners and Physician Assistants

$0 copayment for each visit.

Preventive Care

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$0 copayment.

Preventive services may be covered by Medicare during the benefit year.

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare-covered Benefits Health Need Covered or Problem Benefit

You want to see a doctor (continued)

Preventive Care (continued)

Your Cost Share

What You Should Know

• Abdominal aortic aneurysm screening • Alcohol misuse screenings & counseling • Annual “wellness” visit • Bone mass measurement • Breast cancer screening (mammogram) • Cardiovascular disease (behavioral therapy) • Cardiovascular screening • Cervical and vaginal cancer screening • Colorectal cancer screenings - Multi-target stool DNA tests - Screening barium enemas - Screening colonoscopies - Screening fecal occult blood tests - Screening flexible sigmoidoscopies • Depression screening • Diabetes screenings and monitoring • Diabetes self-management training • Glaucoma tests • Hepatitis B Virus (HBV) infection screening 25

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare-covered Benefits Health Need Covered or Problem Benefit

You want to see a doctor (continued)

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Preventive Care (continued)

Your Cost Share

What You Should Know

• Hepatitis C Screening • HIV screening • Lung cancer screenings • Medical nutrition therapy services • Obesity screenings and counseling • Prostate cancer screenings (PSA) • Sexually transmitted infections (STI) screening and counseling • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) • Vaccines, including flu shots, hepatitis B shots, pneumococcal shots • “Welcome to Medicare” preventive visit (one time)

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare-covered Benefits Health Need Covered or Problem Benefit Emergency Care

Your Cost Share

What You Should Know

$90 copayment for each visit.

If you are admitted to the hospital within 24 hour there is no cost share.

$65 copayment for each visit.

This benefit is also available through Telehealth.

Please call your current provider for details.

You Need Emergency Care Urgent Care

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare-covered Benefits Health Need Covered or Problem Benefit

You need medical tests

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Your Cost Share

Diagnostic Services/Labs/ Imaging: • Outpatient Blood Services • Medicarecovered Lab Services • Diagnostic $0 copayment for Tests and Procedures each service.

• Outpatient X-Rays • Medical Supplies • Diagnostic Radiological Services (such as MRI scans and CT scans)

What You Should Know

Authorization required for certain covered services/items.

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare-covered Benefits Health Need Covered or Problem Benefit

You need medical tests (continued)

Your Cost Share

What You Should Know

Diagnostic Services/Labs/ Imaging: • Therapeutic 20% coinsurance Radiology for each service.

Services (such as radiation treatment for cancer)

Authorization Required.

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare-covered Benefits Health Need Covered or Problem Benefit

Your Cost Share

What You Should Know

$0 copayment for Medicare-covered diagnostic hearing exams.

Hearing Exams You need Hearing Care

Hearing Aids

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$0 copayment for Non-Medicarecovered (Routine) Hearing Exams.

You may receive one Non-Medicarecovered (Routine) Hearing Exam every three years.

Up to $2,000 for both ears combined every 3 years. $0 copayment for Fitting/Evaluation for Hearing Aid every 3 years.

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

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare-covered Benefits Health Need Covered or Problem Benefit

You need Dental Care

Your Cost Share

What You Should Know

Dental Services

20% coinsurance for Medicare‑covered Comprehensive Dental Services.

Referral is required for Comprehensive Dental services

Preventive Dental Services are not covered.

Not Covered $0 Copayment for Medicare-covered eye exams.

You need Eye Care

Vision Exams

$0 Copayment for Non-Medicarecovered (Routine eye exam for eyewear.)

You may receive one Non-Medicarecovered (Routine) Eye Exam every year.

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare-covered Benefits Health Need Covered or Problem Benefit

You need Eye Care (continued)

You need Mental Health Care

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Vision Eyewear

Your Cost Share

What You Should Know

$0 copayment for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery. $0 copayment for Non-Medicarecovered eyewear (Routine) up to $500 maximum every 2 years.

Includes contact lenses and eyewear.

You pay per admission: • Days 1–6: $300 copayment each Authorization is Inpatient day.

Mental Health required.

• Day 7 and beyond: You pay a $0 copayment each day.

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare-covered Benefits Health Need Covered or Problem Benefit

You need Mental Health Care (continued)

Outpatient Mental Health

Your Cost Share

What You Should Know

Mental Health: 50% coinsurance for Individual and Group sessions.

This benefit is also available through Telehealth.

Please call your current provider for details.

This benefit is also available Psychiatric Services: through 45% coinsurance for Telehealth.

Individual and Group Please call your sessions. current provider for details.

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare-covered Benefits

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Health Need Covered or Problem Benefit

Your Cost Share

What You Should Know

You need RehabiliSkilled Nursing tative or Facility Skilled Nursing Care

You pay per admission: • Days 1–20: $0 copayment each day.

• Days 21–100: $184 copayment each day.

• Days 101 and beyond: you pay all cost

The plan covers up to 100 days each benefit period, a 3-day prior hospital stay is required.

Authorization is required.

You need Outpatient Therapy

$30 copayment for each visit.

Authorization is required.

Physical Therapy

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare-covered Benefits Health Need Covered or Problem Benefit

Ambulance You need help getting to health services

You need drugs to treat your illness or condition

Your Cost Share

What You Should Know

Ground Transportation: $100 copayment for each one-way trip.

Air Transportation: 20% coinsurance for each one-way trip.

Authorization is only required for non-emergency services.

$0 copayment.

You may take up to 6 one-way trips Transportation for medical and therapeutic-related purposes every quarter.

Medicare Part B Drugs

20% coinsurance for Medicare Part B prescription drugs.

You may take a taxi, bus/ subway or van.

Authorization is required for certain items.

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare Part D If you qualify for Low-Income Subsidy (also called “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.

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Part D Premium

$42.30 per month

Part D Deductible

Tier 1, 2, and 3 Drugs: Part D deducible is $0.

Tier 4 and 5 Drugs: Part D deducible is $445.

Members pay the full cost of their drugs until their $445 deductible is met, then the cost-shares are applied in the initial coverage stage.

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare Part D Part D Deductible & Initial Coverage Stage Initial Coverage Stage Tier Name

Mail Order Retail Retail Part D Pharmacy Pharmacy Pharmacy Deductible Cost-share Cost-share Cost-share (90-day (30-day (90-day supply)^ supply)* supply)

Tier 1: Preferred Generic Drugs Tier 2: Generic Drugs

$4 $12 $8 Copayment Copayment Copayment $0

$14 $42 $28 Copayment Copayment Copayment

Tier 3: Preferred Brand Drugs

$47 $121 $94 Copayment Copayment Copayment

Tier 4: Non‑Preferred Drugs

25% 25% 25% Coinsurance Coinsurance Coinsurance

Tier 5: Specialty Tier Drugs

$445

25% 25% 25% Coinsurance Coinsurance Coinsurance

*One-month supply for Standard retail (in-network), Long-term care (31-day), and out-of-network cost-share. ^60-Day supply is also available for Standard retail (in-network).

Once your total drug costs have reached $4,130, you will move to the next stage (the Coverage Gap stage).

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Medicare Part D Coverage Gap Stage You pay 25% of the price for brand name drugs (plus a portion of the dispensing fee) and 25% of the price for generic drugs.

If you receive Extra Help, you will not enter the Coverage Gap Stage. Instead, you will continue to pay the Initial Coverage Stage cost-sharing until the Catastrophic Stage.

You stay in this stage until your “out-of-pocket costs” (your payments) reach a total of $6,550. This amount and rules for counting costs toward this amount have been set by Medicare.

Catastrophic Coverage Stage Once your “out-of-pocket costs” (your payments) reach a total of $6,550, you stay in this payment stage until the end of the calendar year.

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Catastrophic Coverage Cost-Sharing

You pay either a coinsurance or copayment, whichever is larger:

For Generic Drugs (including brand drugs treated as generic):

$3.70 copayment - or 5% coinsurance

For All Other Drugs:

$9.20 copayment - or 5% coinsurance

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Other Covered Services Health Need or Problem

You need Medical Equipment and Supplies

Covered Benefit

Your Cost Share

What You Should Know

Durable Medical Equipment (like wheelchairs or oxygen)

20% coinsurance for Medicarecovered Durable Medical Equipment (DME).

Authorization is only required for certain items.

Medical Supplies

$0 copayment for Medical Supplies.

Authorization is required.

20% coinsurance Prosthetics (artificial limbs for Prosthetic Devices. or braces)

Authorization is required.

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Other Covered Services

You need Rehabilitation Services

Physical Therapy, Occupational Therapy, Speech Language Therapy.

$30 copayment.

Authorization is required.

Cardiac Rehabilitation

Cardiac Rehabilitation: $50 copayment for services.

Intensive Rehabilitation: $100 copayment for services.

Authorization is required.

$30 copayment for Pulmonary rehabilitation services.

Authorization is required.

You need Pulmonary Rehabilitation Rehabilitation Services

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Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

More benefits with your plan Acupuncture Services

$10 copayment per visit. You may receive up to 20 visits per year.

OTC

You may purchase up to $25 every month of eligible OTC items on an OTC card provided by Elderplan.

Routine Podiatry Services

$10 copayment per visit. You may receive up to 6 visits per year.

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Elderplan, Inc. Notice of Nondiscrimination – Discrimination is Against the Law 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. Elderplan, Inc. does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Elderplan/HomeFirst.: •

Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)

•

Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you believe that If you need these services, contact Civil Rights Coordinator.

Elderplan/HomeFirst has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you may file a grievance with: Civil Rights Coordinator 6323 7th Ave Brooklyn, NY, 11220 Phone: 1-877-326-9978, TTY 711 Fax: 1-718-759-3643 You may file a grievance in person or by mail, phone, or fax. If you need help filing a grievance, Civil Rights Coordinator, is available to help you.

You may also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW, Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 1-800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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Multi-language Interpreter Services 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).

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

(Chinese) 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).

(Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-353-3765 (телетайп: 711).

(French Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-353-3765 (TTY: 711).

(Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-353-3765 (TTY: 711)번으로 전화해 주십시오.

(Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-353-3765 (TTY: 711). .‫ זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל‬,‫ אויב איר רעדט אידיש‬:‫) אויפמערקזאם‬Yiddish( .1-800-353-3765 (TTY: 711) ‫רופט‬ (Bengali) লক্ষ্য করুনঃ যদি আপদন বা​াংলা, কথা বলতে পাতেন, োহতল দনঃখেচায় ভাষা সহায়ো পদেতষবা উপলব্ধ আতে। ফ ান করুন 1-800-353-3765 (TTY: 711)। (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.

Zadzwoń pod numer 1-800-353-3765 (TTY: 711). ‫ فإن خدمات المساعدة اللغوية تتوافر‬،ASL ‫ إذا كنت تتحدث لغة غير اإلنجليزية أو تحتاج إلى مساعدة في‬:‫)ملحوظة‬Arabic( .1-800-353-3765 (TTY: 711) ‫ اتصل برقم‬.‫لك مجانا‬ (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-353-3765 (ATS: 711). ‫ تو آپ کو زبان کی مدد کی خدمات مفت ميں دستياب ہيں ۔ کال کريں‬،‫ اگر آپ اردو بولتے ہيں‬:‫(خبردار‬Urdu) .1-800-353-3765 (TTY: 711) (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-353-3765 (TTY: 711).

(Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-353-3765 (TTY: 711).

(Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-800-353-3765 (TTY: 711).

43

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Pre-Enrollment Checklist Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at 1-800-353-3765.

Understanding the Benefits Review the full list of benefits found in the Evidence of

Coverage (EOC), especially for those services for which you routinely see a doctor. Visit www.elderplan.org or call 1-800-353-3765 to view a copy of the EOC. Review the provider directory (or ask your doctor) to make

sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor.

Review the pharmacy directory to make sure the pharmacy

you use for any prescription medicine is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.

44

Summary of Benefits – Elderplan Assist (HMO IE-SNP) 2021

Understanding Important Rules In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.

Benefits, premiums and/or copayments/co-insurance may

change on January 1, 2022.

Except in emergency or urgent situations, we do not cover

services by out-of-network providers (doctors who are not listed in the provider directory).

This plan is an institutional special needs plan (I-SNP). Your

ability to enroll will be based on verification that you, for 90 days or longer, have had or are expected to need the level of services provided in a long-term care (LTC) skilled nursing facility (SNF), a LTC nursing facility (NF), a SNF/NF, an intermediate care facility for individuals with intellectual disabilities (ICF/IDD), or an inpatient psychiatric facility.

45

For more information, call us toll-free

1-800-353-3765 8 a.m.– 8 p.m., 7 days a week.

TTY/TDD users should call

711 Visit our website

Elderplan.org

Elderplan is an HMO plan with Medicare and Medicaid contracts. Enrollment in Elderplan depends on contract renewal. Anyone entitled to Medicare Parts A and B may apply. Enrolled members must continue to pay their Medicare part B premium if not otherwise paid for under Medicaid.

2021 Star Ratings Elderplan - H3347 2021 Medicare Star Ratings Every year, Medicare evaluates plans based on a 5-star rating system. Medicare Star Ratings help you know how good a job our plan is doing.

You can use these Star Ratings to compare our plan's performance to other plans. The two main types of Star Ratings are: 1. An Overall Star Rating that combines all of our plan's scores.

2. Summary Star Ratings that focus on our medical or our prescription drug services.

Some of the areas Medicare reviews for these ratings include: How our members rate our plan's services and care; How well our doctors detect illnesses and keep members healthy; How well our plan helps our members use recommended and safe prescription medications.

For 2021, Elderplan received the following Overall Star Rating from Medicare.

3.5 Stars We received the following Summary Star Ratings for Elderplan's health/drug plan services: Health Plan Services:

3.5 Stars

Drug Plan Services:

4 Stars

The number of stars shows how well our plan performs.

5 stars - excellent 4 stars - above average 3 stars - average 2 stars - below average 1 star - poor Learn more about our plan and how we are different from other plans at www.medicare.gov.

You may also contact us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time at 866-695-8101 (toll-free) or 711 (TTY).

Current members please call 800-353-3765 (toll-free) or 711 (TTY).

Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year to the next.

H3347_EP17008_M

47

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SECTION 2

Ready to Enroll Now? There’s never been a better time to become an Elderplan member. In the following pages you will find all of the necessary forms you will need.

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Attestation of Eligibility for an Enrollment Period Name: ______________________________________________________________________________ Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period.

Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period.

If we later determine that this information is incorrect, you may be disenrolled. q I am new to Medicare. q I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP). q I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me. I moved on (insert date) _______ / _______ / _______. q I recently was released from incarceration. I was released on (insert date) _______ / _______ / _______. q I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date) _______ / _______ / _______. q I recently obtained lawful presence status in the United States. I got this status on (insert date) _______ / _______ / _______. q I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid) on (insert date) _______ / _______ / _______. q I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change in the level of Extra Help, or lost Extra Help) on (insert date) _______ / _______ / _______. q I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums).or I get Extra Help paying for my Medicare prescription drug coverage, but I haven’t had a change. q I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long term care facility). I moved/will move into/out of the facility on (insert date) _______ / _______ / _______. q I recently left a PACE program on (insert date) _______ / _______ / _______. q I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost my drug coverage on (insert date) _______ / _______ / _______.

Member Services: 1-800-353-3765 (TTY/TDD 711) 8 a.m.–8 p.m., 7 days a week 6323 Seventh Avenue, Brooklyn NY, 11220 www.elderplan.org White Copy: To Office

Yellow Copy: To Member

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Attestation of Eligibility for an Enrollment Period continued Name: ______________________________________________________________________________ q I am leaving employer or union coverage on (insert date) _______ / _______ / _______. q I belong to a pharmacy assistance program provided by my state. q My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan. q I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My enrollment in that plan started on (insert date) _______ / _______ / _______. q I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to be in that plan. I was disenrolled from the SNP on (insert date) _______ / _______ / _______. q I was affected by a weather-related emergency or major disaster (as declared by the Federal Emergency Management Agency (FEMA). One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster. q I am enrolling during Annual Enrollment Period (October 15th through December 7th) If none of these statements applies to you or you’re not sure, please contact Elderplan at 1-800-353-3765 (TTY users should call 711) to see if you are eligible to enroll. We are open 8 a.m. – 8 p.m., 7 days a week for more information.

Member Services: 1-800-353-3765 (TTY/TDD 711) 8 a.m.–8 p.m., 7 days a week 6323 Seventh Avenue, Brooklyn NY, 11220 www.elderplan.org White Copy: To Office

Yellow Copy: To Member

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OMB OMB No. No. 0938-1378 0938-1378 Expires:7/31/2023 Expires:7/31/2023

INDIVIDUAL INDIVIDUAL ENROLLMENT ENROLLMENT REQUEST REQUEST FORM FORM TO TO ENROLL ENROLL IN IN A A MEDICARE ADVANTAGE PLAN (PART C) OR MEDICARE MEDICARE ADVANTAGE PLAN (PART C) OR MEDICARE PRESCRIPTION PRESCRIPTION DRUG DRUG PLAN PLAN (PART (PART D) D) Who Who can can use use this this form? form?

People People with with Medicare Medicare who who want want to to join join aa Medicare Medicare Advantage Plan or Medicare Prescription Advantage Plan or Medicare Prescription Drug Drug Plan Plan To To join join aa plan, plan, you you must: must: •• Be a United States Be a United States citizen citizen or or be be lawfully lawfully present in the U.S. present in the U.S. •• Live Live in in the the plan’s plan’s service service area area Important: Important: To To join join aa Medicare Medicare Advantage Advantage Plan, Plan, you must also have both: you must also have both: •• Medicare Medicare Part Part A A (Hospital (Hospital Insurance) Insurance) •• Medicare Part B (Medical Medicare Part B (Medical Insurance) Insurance)

When When do do II use use this this form? form?

You You can can join join aa plan: plan: •• Between October Between October 15–December 15–December 77 each each year year (for coverage starting January 1) (for coverage starting January 1) •• Within Within 33 months months of of first first getting getting Medicare Medicare •• In certain situations where you’re In certain situations where you’re allowed allowed to to join join or or switch switch plans plans Visit Visit Medicare.gov Medicare.gov to to learn learn more more about about when when you you can sign up for a plan. can sign up for a plan.

What What do do II need need to to complete complete this this form? form?

Your Your Medicare Medicare Number Number (the (the number number on on your your red, white, and blue Medicare card) red, white, and blue Medicare card) •• Your Your permanent permanent address address and and phone phone number number Note: Note: You You must must complete complete all all items items in in Section Section 1.

1.

The items in Section 2 are optional — The items in Section 2 are optional — you you can’t can’t be be denied denied coverage coverage because because you you don’t don’t fill fill them them out. out.

••

Reminders: Reminders: •• ••

If If you you want want to to join join aa plan plan during during fall fall open open enrollment (October 15–December 7), enrollment (October 15–December 7), the the plan plan must get your completed form by December must get your completed form by December 7.

7.

Your plan will send you a bill for the plan’s Your plan will send you a bill for the plan’s premium. premium. You You can can choose choose to to sign sign up up to to have have your premium payments deducted from your premium payments deducted from your your bank bank account account or or your your monthly monthly Social Social Security Security (or (or Railroad Railroad Retirement Retirement Board) Board) benefit. benefit.

What What happens happens next? next?

Send Send your your completed completed and and signed signed form form to: to: Elderplan Inc. Elderplan Inc. Attention: Attention: Member Member Operations Operations th th Avenue 6323 7 6323 7 Avenue Brooklyn, Brooklyn, NY NY 11220 11220 Once Once they they process process your your request request to to join, join, they’ll contact you. they’ll contact you.

How How do do II get get help help with with this this form? form?

Call Call Elderplan Elderplan Member Member Services Services at at 1-800-353-3765.

TTY users can call 1-800-353-3765. TTY users can call 711.

711.

Or, Or, call call Medicare Medicare at at 1-800-MEDICARE 1-800-MEDICARE (1-800-633-4227).

(1-800-633-4227). TTY TTY users users can can call call 1-877-486-2048 1-877-486-2048 En En español: español: Llame Llame aa Elderplan Elderplan al al 1-800-353-3765/ TTY 1-800-353-3765/ TTY 711 711 oo aa Medicare Medicare gratis gratis al al 1-800-633-4227 1-800-633-4227 yy oprima oprima el el 22 para para asistencia en español y un representante asistencia en español y un representante estará estará disponible disponible para para asistirle. asistirle.

According According to to the the Paperwork Paperwork Reduction Reduction Act Act of of 1995, 1995, no no persons persons are are required required to to respond respond to to aa collection collection of of information information unless unless it it displays displays aa valid valid OMB OMB control control number. number. The The valid valid OMB OMB control control number number for for this this information information collection collection is is 0938-NEW. 0938-NEW. The The time time required required to to complete complete this this information information is is estimated estimated to to average average 20 20 minutes minutes per per response, response, including including the the time time to to review review instructions, instructions, search existing data resources, gather the data needed, and complete and review the information collection. search existing data resources, gather the data needed, and complete and review the information collection. If If you you have have any any comments comments concerning concerning the the accuracy accuracy of of the the time time estimate(s) estimate(s) or or suggestions suggestions for for improving improving this this form, form, please please write write to: to: CMS, CMS, 7500 7500 Security Security Boulevard, Boulevard, Attn: Attn: PRA PRA Reports Reports Clearance Clearance Officer, Officer, Mail Mail Stop Stop C4-26-05, C4-26-05, Baltimore, Baltimore, Maryland Maryland 21244-1850.

21244-1850.

IMPORTANT IMPORTANT Do Do not not send send this this form form or or any any items items with with your your personal personal information information (such (such as as claims, claims, payments, payments, medical medical records, records, etc.) etc.) to to the the PRA PRA Reports Clearance Office.

Any items we get that aren’t about how to improve this form or its collection burden (outlined Reports Clearance Office. Any items we get that aren’t about how to improve this form or its collection burden (outlined in in OMB OMB 0938-1378) 0938-1378) will will be be destroyed. destroyed. It It will will not not be be kept, kept, reviewed, reviewed, or or forwarded forwarded to to the the plan. plan. See See “What “What happens happens next?” next?” on on this this page page to to send send your your completed completed form form to to the the plan. plan.

H3347_EP16942_2021_Medicare_Enrollment_Form_C H3347_EP16942_2021_Medicare_Enrollment_Form_C

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Section11––All Allfields fieldson onthis thispage pageare arerequired required(unless (unlessmarked markedoptional) optional) Section

Select the plan you want to join: Select the plan you want to join:

 Elderplan for Medicaid Beneficiaries  Elderplan for Medicaid Beneficiaries (HMO D-SNP) $35.40 per month (HMO D-SNP) $35.40 per month

 Elderplan Plus Long Term Care  Elderplan Plus Long Term Care (HMO D-SNP) $0.00 per month (HMO D-SNP) $0.00 per month

 Elderplan Advantage for Nursing Home Residents  Elderplan Advantage for Nursing Home Residents (HMO I-SNP) $35.50 per month (HMO I-SNP) $35.50 per month

 Elderplan Extra Help (HMO)  Elderplan Extra Help (HMO) $25.30 per month $25.30 per month  Elderplan Assist (HMO IE-SNP)  Elderplan Assist (HMO IE-SNP) $42.30 per month $42.30 per month

FIRST name: FIRST name:

LAST name: LAST name:

Optional: Middle Initial: Optional: Middle Initial:

Sex: Birth date: (MM/DD/YYYY) Phone number: Sex: Birth date: (MM/DD/YYYY) Phone number:  Male  Female ( ) ( __ __ / __ __ / __ __ __ __ ) Male Female ( ) ( __ __ / __ __ / __ __ __ __ ) Permanent Residence street address (Don’t enter a PO Box): Permanent Residence street address (Don’t enter a PO Box): City: City:

Optional: County: Optional: County:

State: State:

Mailing address, if different from your permanent address (PO Box allowed): Mailing address, if different from your permanent address (PO Box allowed): Street address: City: State: Street address: City: State:

ZIP Code: ZIP Code: ZIP Code: ZIP Code:

Your Medicare information: Your Medicare information: Medicare Number: Medicare Number:

________--______--________

Answer these important questions: Answer these important questions: Will you have other prescription drug coverage (like VA, TRICARE) in addition to Elderplan?

Will you have other prescription drug coverage (like VA, TRICARE) in addition to Elderplan?  Yes  No  Yes  No Name of other coverage: Name of other coverage: _____________________ _____________________

Member number for this coverage: Member number for this coverage: ______________________________ ______________________________

Group number for this coverage Group number for this coverage ___________________________ ___________________________

To enroll in Elderplan Special Need Plan you must meet the criteria listed below and live in our plan To enroll in Elderplan Special Need Plan you must meet the criteria listed below and live in our plan service areas: service areas: Are you enrolled in your New York State Medicaid Program?  Yes  No Are you enrolled in your New York State Medicaid Program?  Yes  No If yes, please provide your New York State Medicaid number: _____________________________ If yes, please provide your New York State Medicaid number: _____________________________ H3347_EP16942_2021_Medicare_Enrollment_Form_C H3347_EP16942_2021_Medicare_Enrollment_Form_C White Copy: To Office

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• Elderplan for Medicaid Beneficiaries (HMO D-SNP), you must be entitled to Medicare and New York • Elderplan for Medicaid Beneficiaries (HMO D-SNP), you must be entitled to Medicare and New York State Medicaid program, you must be eligible for Medicaid coverage and meet the enrollment eligibility State Medicaid program, you must be eligible for Medicaid coverage and meet the enrollment eligibility requirements for Elderplan for Medicaid Beneficiaries. The kind of Medicaid benefits you receive are requirements for Elderplan for Medicaid Beneficiaries. The kind of Medicaid benefits you receive are determined by New York State and may vary based upon your income and resources. determined by New York State and may vary based upon your income and resources.

Are you eligible for Medicare cost-sharing assistance under New York State Medicaid?  Yes Are you eligible for Medicare cost-sharing assistance under New York State Medicaid?  Yes

 No  No

• Elderplan Plus Long Term Care (HMO D-SNP) you must be entitled to Medicare and New York State • Elderplan Plus Long Term Care (HMO D-SNP) you must be entitled to Medicare and New York State Medicaid program, you must be eligible for full benefits from Medicaid and meet the enrollment Medicaid program, you must be eligible for full benefits from Medicaid and meet the enrollment eligibility requirements for Elderplan Plus Long Term Care. The kind of Medicaid benefits you receive eligibility requirements for Elderplan Plus Long Term Care. The kind of Medicaid benefits you receive are determined by New York State and may vary based upon your income and resources. are determined by New York State and may vary based upon your income and resources.

Please indicate if you meet all the following requirements. 1) You are eligible for full New York State Please indicate if you meet all the following requirements. 1) You are eligible for full New York State Medicaid coverage, 2) you are 18 years or older, and 3) you believe you are eligible for a nursing home level Medicaid coverage, 2) you are 18 years or older, and 3) you believe you are eligible for a nursing home level of care, are capable of safely remaining in your home, and require care management and home care or day of care, are capable of safely remaining in your home, and require care management and home care or day care services for 120 continuous days or longer?  Yes  No care services for 120 continuous days or longer?  Yes  No To enroll in Elderplan Special Needs Plan you must meet the criteria listed below and live in our To enroll in Elderplan Special Needs Plan you must meet the criteria listed below and live in our plan service areas: plan service areas: • Elderplan Advantage for Nursing Home Residents (HMO I-SNP) you must live in an institutional • Elderplan Advantage for Nursing Home Residents (HMO I-SNP) you must live in an institutional nursing home contracted with Elderplan Special Needs Plan. nursing home contracted with Elderplan Special Needs Plan.

Do you reside or expect to reside in a contracted nursing facility within the service area?  Yes  No Do you reside or expect to reside in a contracted nursing facility within the service area?  Yes  No Are you a resident in a long-term care facility, such as a nursing home?  Yes  No Are you a resident in a long-term care facility, such as a nursing home?  Yes  No If “yes,” please provide the following information: If “yes,” please provide the following information: Name of Institution: _______________________________________________________________________ Name of Institution: _______________________________________________________________________ Address & Phone Number of Institution (number and street): _______________________________________ Address & Phone Number of Institution (number and street): _______________________________________ • Elderplan Assist (HMO IE-SNP) your current residence should be an assisted living facility while also • Elderplan Assist (HMO IE-SNP) your current residence should be an assisted living facility while also getting nursing home level of care. getting nursing home level of care.

Do you reside or expect to reside in a contracted nursing facility within the service area?  Yes  No Do you reside or expect to reside in a contracted nursing facility within the service area?  Yes  No – or – – or – Do you live at home and New York State has certified that you need the type of care that is usually provided Do you live at home and New York State has certified that you need the type of care that is usually provided in a nursing home?  Yes  No in a nursing home?  Yes  No Are you a resident in a long-term care facility, such as a nursing home?  Yes  No Are you a resident in a long-term care facility, such as a nursing home?  Yes  No If “yes,” please provide the following information: If “yes,” please provide the following information: Name of Institution: ________________________________________________________________________ Name of Institution: ________________________________________________________________________ Address & Phone Number of Institution (number and street): _______________________________________ Address & Phone Number of Institution (number and street): _______________________________________ H3347_EP16942_2021_Medicare_Enrollment_Form_C H3347_EP16942_2021_Medicare_Enrollment_Form_C White Copy: To Office

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IMPORTANT: Read and sign below: IMPORTANT: Read and sign below: • I must keep both Hospital (Part A) and Medical (Part B) to stay in Elderplan.

• I must keep both Hospital (Part A) and Medical (Part B) to stay in Elderplan.

• By joining this Medicare Advantage Prescription Drug Plan, I acknowledge that Elderplan will share • By joining this Medicare Advantage Prescription Drug Plan, I acknowledge that Elderplan will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act Statement purposes allowed by Federal law that authorize the collection of this information (see Privacy Act Statement below). below).

• Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.

• Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.

• The information on this enrollment form is correct to the best of my knowledge. I understand that if I • The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. intentionally provide false information on this form, I will be disenrolled from the plan.

• I understand that people with Medicare are generally not covered under Medicare while out of the country, • I understand that people with Medicare are generally not covered under Medicare while out of the country, except for limited coverage near the U.S. border. except for limited coverage near the U.S. border.

• I understand that when my Elderplan coverage begins, I must get all of my medical and prescription drug • I understand that when my Elderplan coverage begins, I must get all of my medical and prescription drug benefits from Elderplan. Benefits and services provided by Elderplan and contained in my Elderplan benefits from Elderplan. Benefits and services provided by Elderplan and contained in my Elderplan “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Elderplan will pay for benefits or services that are not covered. covered. Neither Medicare nor Elderplan will pay for benefits or services that are not covered.

• I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this • I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this application means that I have read and understand the contents of this application. If signed by an authorized application means that I have read and understand the contents of this application. If signed by an authorized representative (as described above), this signature certifies that: representative (as described above), this signature certifies that: 1) This person is authorized under State law to complete this enrollment, and 1) This person is authorized under State law to complete this enrollment, and 2) Documentation of this authority is available upon request by Medicare.

2) Documentation of this authority is available upon request by Medicare.

Signature: Today’s date: Signature: Today’s date: If you’re the authorized representative, sign above and fill out these fields: If you’re the authorized representative, sign above and fill out these fields: Name: Address: Name: Address: Phone number: Phone number:

Relationship to enrollee: Relationship to enrollee:

H3347_EP16942_2021_Medicare_Enrollment_Form_C H3347_EP16942_2021_Medicare_Enrollment_Form_C White Copy: To Office

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Section 2 – All fields on this page are optional Section 2 – All fields on this page are optional Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.

Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.

Select one if you want us to send you information in a language other than English.  Spanish Select one if you want us to send you information in a language other than English.  Spanish Select one if you want us to send you information in an accessible format.

Select one if you want us to send you information in an accessible format.  Braille  Large print  Audio CD  Braille  Large print  Audio CD Please contact Elderplan 1-800-353-3765 if you need information in an accessible format other than what’s listed Please Elderplan 1-800-353-3765 if 7you need information in ancan accessible above. contact Our office hours are 8 AM to 8 PM, days a week.

TTY users call 711.format other than what’s listed above. Our office hours are 8 AM to 8 PM, 7 days a week. TTY users can call 711.

Do you work?  Yes  No Does your spouse work?  Yes  No Do you work?  Yes  No Does your spouse work?  Yes  No List your Primary Care Physician (PCP), clinic, or health center: List your Primary Care Physician (PCP), clinic, or health center: I want to get the following materials via email. Select one or more.

I want to get the following materials via email. Select one or more.  Summary of Benefits  Evidence of Coverage  Annual Notice of Change  Summary of Benefits  Evidence of Coverage  Annual Notice of Change  Provider/ Pharmacy Directories  Formularies  Provider/ Pharmacy Directories  Formularies E-mail address: ______________________________________________________________________________ E-mail address: ______________________________________________________________________________ Paying your plan premiums Paying your plan premiums You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe)can by mail “Electronic Transfer (EFT)”, “credit card” each month.

Youthat canyou alsocurrently choose have to pay You pay your monthlyFunds plan premium (including any late enrollment penalty oryour may premium by having it automatically taken out of“credit your Social or Railroad owe) by mail “Electronic Funds Transfer (EFT)”, card”Security each month.

You canRetirement also chooseBoard to pay(RRB) your benefit each premium by month. having it automatically taken out of your Social Security or Railroad Retirement Board (RRB) benefit each month.

If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you must pay this extra addition to your plan premium.

The amount is usually(Part taken D-IRMAA), out of your Social Security If you haveamount to pay in a Part D-Income Related Monthly Adjustment Amount you must pay benefit, or amount you may in getaddition a bill from Medicare the RRB).

DON’T pay the Part D-IRMAA. this extra to your plan(or premium.

The amount is Elderplan usually taken out of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DON’T pay Elderplan the Part D-IRMAA.

H3347_EP16942_2021_Medicare_Enrollment_Form_C White Copy: To Office H3347_EP16942_2021_Medicare_Enrollment_Form_C

63 Yellow Copy: To Member

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 Electronic funds transfer (EFT) from your bank account each month. Please enclose a VOIDED check or provide the following: Account holder name: ________________________________________________________________ Bank routing number: __________________________ Bank account number: ___________________ Account type:  Checking  Saving Please select a premium payment option:  Credit Card. Please provide the following information:  Get a bill.

Type of Card: ______________________________________________________________________  Electronic funds transfer (EFT) from your bank account each month. Please enclose a VOIDED check Name of Account holder as it appears on card:____________________________________________ or provide the following: Account number: ___________________________________________________________________ Account holder name: ________________________________________________________________ Expiration Date: ________ /________________ (MM/YYYY) Bank routing number: __________________________ Bank account number: ___________________  Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) Account type:  Checking  Saving benefit check.  Credit Card. Please provide the following information: I get monthly benefits from:  Social Security  Railroad Retirement Board (RRB) Type of Card: ______________________________________________________________________ Name of Account holder as it appears on card:____________________________________________ (The Social Security or RRB deduction may take two or more months to begin after Social Security or RRB Account number: ___________________________________________________________________ approves the deduc-tion. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction Social Security or RRB benefit check will include all premiums due from your Expirationfrom Date:your ________ /________________ (MM/YYYY) enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your  Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) request for automatic deduction, we will send you a paper bill for your monthly premiums.) benefit check.

I get monthly benefits from:

 PRIVACY Social Security  Railroad Retirement Board (RRB) ACT STATEMENT The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) or Prescription Drug Plans (PDP), improve care, and for the payment of (The Social Security or RRB may of take or more months to begin after Security RRB and Medicare benefits.

Sections 1851deduction and 1860D-1 thetwo Social Security Act and 42 CFR §§Social 422.50, 422.60,or423.30 approves the deduc-tion.

In most if Social Security RRBuse, accepts yourand request for automatic deduction, 423.32 authorize the collection of cases, this information.

CMSormay disclose exchange enrollment data from the first deduction from your Social Security or RRB benefit check will include all premiums due from yourDrug Medicare beneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage Prescription enrollment effective up to theYour pointresponse withholding begins.

Security or RRB does to notrespond approvemay your (MARx)”, System No. date 09-70-0588. to this form If is Social voluntary.

However, failure affect request for automatic deduction, we will send you a paper bill for your monthly premiums.) enrollment in the plan.

PRIVACY ACT STATEMENT The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) or Prescription Drug Plans (PDP), improve care, and for the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50, 422.60, 423.30 and 423.32 authorize the collection of this information. CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.

H3347_EP16942_2021_Medicare_Enrollment_Form_C Member Services: 1-800-353-3765 (TTY/TDD 711) 8 a.m.–8 p.m., 7 days a week 6323 Seventh Avenue, Brooklyn NY, 11220 www.elderplan.org White Copy: To Office

H3347_EP16942_2021_Medicare_Enrollment_Form_C

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New York State Department of Health

Authorization for Access to Patient Information Through a Health Information Exchange Organization

Patient Name ______________________________________________________________________________________ DOB: ________________ Patient Identification Number: __________________________________________________ Patient Address _____________________________________________________________________________________ I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose whether or not to allow Elderplan to obtain access to my medical records through the health information exchange organization called Healthix. If I give consent, my medical records from different places where I get health care can be accessed using a statewide computer network. Healthix is a not-for-profit organization that shares information about people’s health electronically and meets the privacy and security standards of HIPAA and New York State Law. To learn more visit Healthix’s website at www.healthix.org.

The choice I make in this form will NOT affect my ability to get medical care. The choice I make in this form does NOT allow health insurers to have access to my information for the purpose of deciding whether to provide me with health insurance coverage or pay my medical bills.

My Consent Choice. ONE box is checked to the left of my choice I can fill out this form now or the future.

I can also change my decision at any time by completing a new form. q

1. I GIVE CONSENT for Elderplan to access ALL of my electronic health information through Healthix to provide health care.

q

2. I DENY CONSENT for Elderplan to access my electronic health information through Healthix for any purpose.

If I want to deny consent for all Provider Organizations and Health Plans participating in Healthix to access my electronic health information through Healthix, I may do so by visiting Healthix’s website at www.healthix.org or calling Healthix at 877-695-4749.

My questions about this form have been answered and I have been provided a copy of this form. _______________________________________________________ Signature of Patient or Patient’s Legal Representative

________________________________________ Date

_______________________________________________________ Print Name of Legal Representative (if applicable)

________________________________________ Relationship of Legal Representative to Patient (if applicable)

Member Services: 1-800-353-3765 (TTY/TDD 711) 8 a.m.–8 p.m., 7 days a week 6323 Seventh Avenue, Brooklyn NY, 11220 www.elderplan.org DOH [Form number pending] 6/14

White Copy: To Office

Yellow Copy: To Member

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Details about the information accessed through Healthix and the consent process: 1. H ow Your Information May be Used. Your electronic health information will be used only for the following healthcare services: • Insurance Eligibility Verification. Check whether you have health insurance and what it covers.

• Care Management Activities. These include assisting you in obtaining appropriate medical care, improving the quality of services provided to you, coordinating the provision of multiple health care services provided to you, or supporting you in following a plan of medical care.

• Quality Improvement Activities. Evaluate and improve the quality of medical care provided to you and all patients.

2. What Types of Information about You Are Included. If you give consent, the Provider Organization listed may access ALL of your electronic health information available through Healthix. This includes information created before and after the date this form is signed. Your health records may include a history of illnesses or injuries you have had (like diabetes or a broken bone), test results (like X-rays or blood tests), and lists of medicines you have taken. This information may include sensitive health conditions, including but not limited to: • Alcohol or drug use problems & diagnoses • Genetic (inherited) diseases or tests • Mental health conditions • Birth control and abortion (family planning) • HIV/AIDS • Sexually transmitted diseases 3. Where Health Information About You Comes From. Information about you comes from places that have provided you with medical care or health insurance. These may include hospitals, physicians, pharmacies, clinical laboratories, health insurers, the Medicaid program, and other organizations that exchange health information electronically. A complete, current list is available from Healthix. You can obtain an updated list at any time by visiting Healthix’s website at www.healthix.org or by calling 877-695-4749.

4. Who May Access Information About You, If You Give Consent. Only doctors and other staff members of the Organization(s) you have given consent to access who carry out activities permitted by this form as described above in paragraph 1 above.

5. Public Health and Organ Procurement Organization Access. Federal, state or local public health agencies and certain organ procurement organizations are authorized by law to access health information without a patient’s consent for certain public health and organ transplant purposes. These entities may access your information through Healthix for these purposes without regard to whether you give consent, deny consent or do not fill out a consent form.

6. Penalties for Improper Access to or Use of Your Information. There are penalties for inappropriate access to or use of your electronic health information. If at any time you suspect that someone who should not have seen or gotten access to information about you has done so, call Elderplan at: 1-800-353-3765; or visit Healthix’s website: www.healthix.org; or call the NYS Department of Health at 518-474-4987; or follow the complaint process of the federal Office for Civil Rights at the following link: http://www.hhs.gov/ocr/privacy/hipaa/complaints/.

7. Re-disclosure of Information. Any organization(s) you have given consent to access health information about you may re-disclose your health information, but only to the extent permitted by state and federal laws and regulations.

Alcohol/drug treatment-related information or confidential HIV-related information may only be accessed and may only be re-disclosed if accompanied by the required statements regarding prohibition of re-disclosure.

8. Effective Period. This Consent Form will remain in effect until the day you change your consent choice, death or until such time as Healthix ceases operation. If Healthix merges with another Qualified Entity your consent choices will remain effective with the newly merged entity.

9. Changing Your Consent Choice. You can change your consent choice at any time and for any Provider Organization or Health Plan by submitting a new Consent Form with your new choice. Organizations that access your health information through Healthix while your consent is in effect may copy or include your information in their own medical records.

Even if you later decide to change your consent decision they are not required to return your information or remove it from their records.

10. Copy of Form. You are entitled to get a copy of this Consent Form.

Member Services: 1-800-353-3765 (TTY/TDD 711) 8 a.m.–8 p.m., 7 days a week 6323 Seventh Avenue, Brooklyn NY, 11220 www.elderplan.org 68

Elderplan, Inc. Notice of Privacy Practices EFFECTIVE DATE: 9/1/2020

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This notice summarizes the privacy practices of Elderplan Inc. (the “Plan”), its workforce, medical staff, and other health professionals. We may share protected health information (“PHI” or “Health Information”) about you with each other for purposes described in this notice, including for the Plan’s administrative activities.

The Plan is committed to safeguarding the privacy of our members’ PHI. PHI is information which: (1) identifies you (or can reasonably be used to identify you); and (2) relates to your physical or mental health or condition, the provision of health care to you or the payment for that care.

OUR OBLIGATIONS

• We are required by law to maintain the privacy and security of your PHI. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION The following categories describe different ways that we may use and disclose Health Information.

Not every use or disclosure permitted in a category is listed below, but the categories provide examples of the uses and disclosures permitted by law.

Payment. We may use and disclose Health Information process and pay claims submitted to us by your or by physicians, hospitals and other health care providers for services provided to you. For example, other payment purposes may include the use of Health Information to determine eligibility for benefits, coordination of benefits, collection of premiums, and medical necessity. We may also share your information with another health plan that provides or has provided coverage to you for payment purposes or for detecting or preventing health care fraud and abuse.

Health Care Operations. We may use and disclose Health Information for health care operations, which are administrative activities involved in operating the Plan. For example, we may use Health Information to operate and manage our business activities related to providing and managing your health care coverage or resolving grievances.

Treatment. We may disclose your Health Information with your health care provider (pharmacies, physicians, hospitals, etc.) to help them provide care to you. For example, if you are in the hospital, we may disclose information sent to us by your physician.

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Appointment Reminders, Treatment Alternatives, and Health-Related Benefits and Services.

We may use and disclose Health Information to contact you as a reminder that you have an appointment/visit with us or your health care provider. We also may use and disclose Health Information to tell you about treatment options, alternatives, health-related benefits, or services that may be of interest to you.

By providing us with certain information, you expressly agree that the Plan and its business associates can use certain information (such as your home/work/cellular telephone number and your email), to contact you about various matters, such as follow up appointments, collection of amounts owed and other operational matters. You agree you may be contacted through the information you have provided and by use of pre-recorded/artificial voice messages and use of an automatic/predictive dialing system.

Individuals Involved in Your Care or Payment for Your Care. We may disclose Health Information to a person, such as a family member or friend, who is involved in your medical care or helps pay for your care. We also may notify such individuals about your location or general condition, or disclose such information to an entity assisting in a disaster relief effort. In these cases, we will only share the Health Information that is directly relevant to the person’s involvement in your health care or payment related to your health care.

Personal Representatives. We may disclose your Health Information to your personal representative, if any. A personal representative has legal authority to act on your behalf in making decisions related to your health care or care payment. For example, we may disclose your Health Information to a durable power of attorney or legal guardian.

Research. Under certain circumstances, as an organization that performs research, we may use and disclose Health Information for research purposes. For example, a research project may involve comparing the health and recovery of all members who received one medication or treatment to those who received another, for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process. This process evaluates a proposed research project and its use of Health Information to balance the benefits of research with the need for privacy of Health Information. We also may permit researchers to look at records to help them identify members who may be included in their research project or for other similar purposes.

Fundraising Activities. We may use or disclose your demographic information (e.g., name, address, telephone numbers and other contact information), the dates of health care provided to you, your health care status, the department and physician(s) who provided you services, and your treatment outcome information in contacting you in an effort to raise funds in support of the Plan and other non-profit entities with whom we are conducting a joint fundraising project. We may also disclose your Health Information to a related foundation or to our business associates so that they may contact you to raise funds for us. If we do use or disclose your Health Information for fundraising purposes, you will be informed of your rights to opt-out of receiving further fundraising communications.

SPECIAL CIRCUMSTANCES In addition to the above, we may use and disclose Health Information in the following special circumstances. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

As Required by Law. We will disclose Health Information when required to do so by international, federal, state or local law.

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To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to prevent or lessen a serious threat to your health or safety, or the health or safety of the public or another person. Any disclosure, however, will be to someone who we believe may be able to help prevent the threat.

Business Associates. We may disclose Health Information to the business associates that we engage to provide services on our behalf if the information is needed for such services. For example, we may use another company to perform billing services on our behalf. Our business associates are obligated, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract with them.

Organ and Tissue Donation. If you are an organ donor, we may release Health Information to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank, as necessary, to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

Workers’ Compensation. We may disclose Health Information as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; track certain products and monitor their use and effectiveness; if authorized by law, notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and conduct medical surveillance of our facilities in certain limited circumstances concerning workplace illness or injury. We also may release Health Information to an appropriate government authority if we believe a member has been the victim of abuse, neglect or domestic violence; however, we will only release this information if the member agrees or when we are required or authorized by law.

Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure of our facilities and providers. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Legal Actions. We may disclose Health Information in response to a court or administrative order, or in response to a subpoena, discovery request, or other lawful process by someone else involved in a legal action, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release Health Information if asked by a law enforcement official as follows: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness or missing person; (3) about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about evidence of criminal conduct on our premises; and (6) in emergency circumstances to report a crime, the location of the crime or victims or the identity, description or location of the person who committed the crime.

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Coroners, Medical Examiners and Funeral Directors. We may release Health Information to a coroner or medical examiner. In some circumstances this may be necessary, for example, to determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.

National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counter-intelligence and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates or Individuals in Custody. In the case of inmates of a correctional institution or that are under the custody of a law enforcement official, we may release Health Information to the appropriate correctional institution or law enforcement official. This release would be made only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Additional Restrictions on Use and Disclosure: Some kinds of Health Information including, but not limited to, information related to alcohol and drug abuse, mental health treatment, genetic, and confidential HIV related information require written authorization prior to disclosure and are subject to separate special privacy protections under the laws of the State of New York or other federal laws, so that portions of this notice may not apply.

In the case of genetic information, we will not use or share your genetic information for underwriting purposes.

If a use or sharing of Health Information described above in this Notice is prohibited or otherwise limited by other laws that apply to us, our policy is to meet the requirements of the more stringent law.

USES AND DISCLOSURE REQUIRING WRITTEN AUTHORIZATION In situations other than those described above, we will ask for your written authorization before using or disclosing personal information about you. For example, we will get your authorization: 1) for marketing purposes that are unrelated to your benefit plan, 2) before disclosing any psychotherapy notes, 3) related to the sale of your Health Information, and 4) for other reasons as required by law. For example, state law further requires us to ask for your written authorization before using or disclosing information relating to HIV/AIDS, substance abuse, or mental health information.

You have the right to revoke any such authorizations, except in limited circumstance such as if we have taken action in reliance on your authorization.

YOUR RIGHTS You have the following rights, subject to certain limitations, regarding Health Information that we maintain about you – all requests must be made IN WRITING: Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information that we use or disclose for treatment, payment, or health care operations. You have the right to request a limit on the Health Information that we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required 72

HOW TO EXERCISE YOUR RIGHTS To exercise any of your rights described in this notice, other than to obtain a paper copy of this notice, you must contact the Plan.

Elderplan Attention: Regulatory Compliance 6323 Seventh Avenue Brooklyn, NY 11220 1-800-353-3765 TTY: 711

BREACH NOTIFICATION We will keep your Health Information private and secure as required by law. If there is a breach (as defined by law) of any of your Health Information, then we will notify you within 60 days following the discovery of the breach, unless a delay in notification is requested by law enforcement.

ELECTRONIC HEALTH INFORMATION EXCHANGE The Plan may participate in various systems of electronic exchange of Health Information with other healthcare providers, health information exchange networks and health plans. Your Health Information maintained by the Plan may be accessed by other providers, health information exchange networks and health plans for the purposes of treatment, payment, or health care operations. In addition, the Plan may access your Health Information maintained by other providers, health information exchange networks and health plans for treatment, payment or health care operation purposes but only with your consent.

Member Services: 1-800-353-3765 (TTY/TDD 711) 8 a.m.–8 p.m., 7 days a week 6323 Seventh Avenue, Brooklyn NY, 11220 www.elderplan.org 73

CHANGES TO THIS NOTICE We reserve the right to change this notice and to make the revised or changed notice effective for Health Information that we already have as well as any information we receive in the future. The new notice will be available upon request, on our website, and we will mail a copy to you. The notice will contain the effective date on the first page, in the top left-hand corner.

COMPLAINTS AND QUESTIONS If you believe your privacy rights have been violated, you may file a complaint with us. To file a complaint with us, contact our Privacy Office at the address listed below. All complaints must be made in writing.

Elderplan Attention: Regulatory Compliance 6323 Seventh Avenue Brooklyn, NY 11220 You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

We will not retaliate against you if you exercise your right to file a complaint.

If you have any questions about this notice, please contact 1-855-395-9169 (TTY: 711)

Member Services: 1-800-353-3765 (TTY/TDD 711) 8 a.m.–8 p.m., 7 days a week 6323 Seventh Avenue, Brooklyn NY, 11220 www.elderplan.org 74

SECTION 3

What’s Next?

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Thank you for choosing

Elderplan Assist (HMO IE-SNP)

Here’s what you can expect in the coming weeks: • Verification Letter—Stating that your application has been received and we are in the process of reviewing it.

• Welcome Call—Once your enrollment is confirmed, a Case Manager will call to introduce you to our plan and answer any questions you may have.

• Welcome Packet—You will receive the welcome packet containing important information about your plan.

To request a hard copy of the Evidence of Coverage, Provider/Pharmacy Directory or Formulary (a list of covered drugs) call Member Services or visit www.elderplan.org.

• ID Card and OTC Card—Now you are all set to start accessing your benefits. You’ll need to take your Member ID card with you whenever you go see your doctor or pharmacist. You can use your OTC card at network retailers.

Elderplan puts you first.

We will reach out to you throughout the year to help make sure you are taking advantage of all of the programs the plan has to offer: Speak With Your Dedicated Case Manager: • A Case Manager is a health care professional assigned at enrollment. They will ensure that you or your loved one is getting the care they need. Once coverage begins, your Case Manager will help connect you to programs and services. They will also make their contact information available so you are able to reach them.

Speak With Your Dedicated Practioner: • A registered nurse or Case Manager will be assigned to check on you or your loved one’s health status on a monthly basis. They will work with a designated Practitioner* as part of an Interdisciplinary Care Team (ICT) whose goal is to develop a tailored treatment strategy. The ICT includes your entire care team which is comprised of: nurses, social workers, practitioners, rehab therapists as well as your PCP. Consider Advanced Care Planning: • Several documents are available for our members to express care wishes and help others know what type of medical care is desired. Ask your Case Manager for more information.

Member Services: 1-800-353-3765 (TTY/TDD 711) 8 a.m.–8 p.m., 7 days a week 6323 Seventh Avenue, Brooklyn NY, 11220 www.elderplan.org *The term Practitioner refers to the for following medical professionals: Nurse Practitioner, Physician Assistant and Doctor.

H3347_EP16956_C

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Make Your Health Care Wishes Known Advance Care Planning and Directives You’ve already made an important decision regarding your care by choosing Elderplan. But it doesn’t stop there. It is important to think about your future and what health care decisions you would want your family or loved ones to make on your behalf, should you not be able to decide on your own. These are your decisions to make, regardless of what you choose for your care, and should be discussed with your loved ones.

Below we’ve provided a quick overview of some common terms and options to help you get the conversation started.

Planning in Advance Your Right to Decide About Treatment Adults in New York State have the right to accept or refuse medical treatment, including life-sustaining treatment.

The New York State Constitution and state laws protect this right. This means that you have the right to request or consent to treatment, to refuse treatment before it has started and to have treatment stopped once it has begun.

As a Patient You have the Right to: Plan in Advance Sometimes, because of illness or injury, people are unable to talk to a doctor and decide about treatment for themselves. You may wish to plan in advance to make sure that your wishes about treatment will be followed if you become unable to decide for yourself for a short or long time period. If you don’t plan ahead, family members or other people close to you may not know your wishes for a treatment plan in certain circumstances and they may not make the same treatment decisions that you would desire. Additionally, the person whom you trust most to make your treatment decisions may not be the same person designated by law absent formal legal instructions from you.

In New York State, appointing someone you can trust to decide about treatment if you become unable to decide for yourself is the best way to protect your treatment wishes and concerns. You have the right to appoint someone by filling out a form called a Health Care Proxy. A copy of the form and information about the Health Care Proxy are available from your health care provider.

If you have no one you can appoint to decide for you, or do not want to appoint someone, you can also give specific instructions about treatment in advance. Those instructions can be written, and are often referred to as a Living Will.

Make Decisions About Treatment You should understand that general instructions about refusing treatment may not be effective, even if written down. Your instructions must clearly cover the treatment decisions that must be made. For example, if you just write down that you do not want “heroic measures,” the instructions may not be specific enough. You should say the kind of treatment that you do not want, such as a respirator or chemotherapy, and describe the medical condition when you would refuse the treatment, such as when you are terminally ill or permanently unconscious with no hope of recovering. You can also give instructions orally by discussing your treatment wishes with your doctor, family members or others close to you.

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Definitions The following terms are often used when discussing advance directives: Advance Directives: An advance directive is a written instruction relating to the provision of health care in the event that you become incapacitated. Advance directives might include any of the following: a health care proxy document or power of attorney for health care; a living will; a do-not-resuscitate order.

Living Will: A living will is a document containing specific instructions concerning your wishes regarding health care choices. Historically, the term “living will” was used to describe your wishes regarding choices to be made while you were still alive (as opposed to your “testamentary” will, which expressed your wishes that were to be implemented after your death). Today, the terms “living will” and “advance directives” are used interchangeably.

Health Care Proxy (Form): In New York State, the Health Care Proxy form is the official form document published by the Department of Health which allows you to select a “health care agent” (and an alternate agent, if the first agent is unavailable, if you wish) to make health care decisions on your behalf if you later become incapable of making your own health care decisions. You may also defer to your agent to make decisions on your behalf, even if you retain capacity, and later resume your own decision-making authority.

Health Care Agent: A health care agent is the adult whom you designate on a Health Care Proxy form to make health care decisions on your behalf if at some time in the future you cannot make health care decisions for yourself. The health care agent’s authority begins when your physician determines that you lack the capacity to make decisions about your own health care.

Powers of Attorney: Prior to the creation of the Health Care Proxy form, many people appointed health care agents using a legal document called a “health care power of attorney” or a “durable health care power of attorney” or some other combination of these words. This document is used to appoint an agent to make health care decisions only—not legal or financial decisions. A durable power of attorney for health care is still honored today if that is the form that you have.

In contrast, another power of attorney recognized in New York is the “durable general power of attorney,” also called the “durable statutory financial power of attorney” or some other combination of these words (and note that the words “health care” do not appear in the title of this document). The financial power of attorney allows your agent to manage your finances, to buy and sell property on your behalf, to conduct litigation, to attend to tax matters and to engage in other general financial activities.

The financial power of attorney also allows your agent to pay your health care bills, but it does not entitle your agent to obtain medical records, nor does it allow your agent to make health care decisions on your behalf. In order to designate an agent who is legally authorized to make health care decisions on your behalf should you lose the capacity to make decisions for yourself, you must either designate the agent on a Health Care Proxy form or in a health care power of attorney, or you must make your wishes clearly known to MJHS Home Care prior to your incapacity.

Order Not to Resuscitate (DNR Order): A DNR order is an order signed by a physician under which health care providers may not attempt cardiopulmonary resuscitation (CPR) in the event that you suffer cardiac or respiratory arrest. Non-hospital DNR orders must be recorded on a specific New York State form and signed by a physician in order to be recognized as valid by emergency responders (emergency responders also recognize the MOLST form as a valid method of recording a DNR order).

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MOLST (Form): The MOLST form is a standardized form published by the State Department of Health, and the acronym stands for Medical Orders for Life-Sustaining Treatment. This form is a combination of advance directives and physician orders and is intended to be used by patients with serious health conditions who (a) want to express their wishes regarding life-sustaining treatment; (b) reside in a long-term care facility or require long-term care services; and/or (c) might die within 12 months. In addition to including an option for a DNR order, the MOLST allows for a “do not intubate” (DNI) order. The MOLST form is intended to travel with the patient across all health care settings and is not restricted to use just in a hospital or outside of a hospital (like a DNR order).

Appointing Your Health Care Agent in New York State Health Care Proxy The New York Health Care Proxy Law allows you to appoint someone you trust—for example, a family member or close friend—to make health care decisions for you if you lose the ability to make decisions yourself. By appointing a health care agent, you can make sure that health care providers follow your wishes. Your agent can also decide how your wishes apply as your medical condition changes. Hospitals, doctors and other health care providers must follow your agent’s decisions as if they were your own. You may give the person you select as your health care agent as little or as much authority as you want. You may allow your agent to make all health care decisions or only certain ones. You may also give your agent instructions that he or she has to follow. The Health Care Proxy form can also be used to document your wishes or instructions with regard to organ and/or tissue donation.

About the Health Care Proxy Form It is an important legal document. Before signing, you should understand the following facts: 1. The form gives the person you choose as your agent the authority to make all health care decisions for you, including the decision to remove or provide life-sustaining treatment, unless you say otherwise in the form.

“Health care” means any treatment, service or procedure to diagnose or treat your physical or mental condition.

2. Unless your agent reasonably knows your wishes about artificial nutrition and hydration (nourishment and water provided by a feeding tube or intravenous line), he or she will not be allowed to refuse or consent to those measures for you.

3. Your agent will start making decisions for you when your doctor determines that you are not able to make health care decisions for yourself.

4. You may write on the form examples of the types of treatments that you would not desire and/or those treatments that you want to make sure you receive. The instructions may be used to limit the decision-making power of the agent. Your agent must follow your instructions when making decisions for you.

5. You do not need a lawyer to fill out the form.

6. You may choose any adult (18 years of age or older), including a family member or close friend, to be your agent. If you select a doctor as your agent, he or she will have to choose between acting as your agent or as your attending doctor because a doctor cannot do both at the same time. Also, if you are a patient or resident of a hospital, nursing home or mental hygiene facility, there are special restrictions about naming someone who works for that facility as your agent. Ask staff at the facility to explain those restrictions.

7. Before appointing someone as your health care agent, discuss it with him or her to make sure that he or she is willing to act as your agent. Tell the person you choose that he or she will be your health care agent. Discuss your health care wishes and the form with your agent. Be sure to give him or her a signed copy. Your agent cannot be sued for health care decisions made in good faith.

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8. If you have named your spouse as your health care agent and you later become divorced or legally separated, your former spouse can no longer be your agent by law, unless you state otherwise. If you would like your former spouse to remain your agent, you may note this on your current form after your divorce or legal separation and date it, or complete a new form naming your former spouse.

9. Even though you have signed the form, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be given to you or stopped if you object, nor will your agent have any power to object.

10. You may cancel the authority given to your agent by telling them or your health care provider orally or in writing.

11. Appointing a health care agent is voluntary. No one can require you to appoint one.

12. You may express your wishes or instructions regarding organ and/or tissue donation on the form.

Having a signed Health Care Proxy form is the best way to ensure that health care is provided according to your wishes.

Frequently Asked Questions About Health Care Proxy Q. Why should I choose a health care agent?

A. If you become unable, even temporarily, to make health care decisions, someone else must decide for you.

Health care providers often look to family members for guidance. Family members may express what they think your wishes are related to a particular treatment. However, in New York State, only a health care agent you appoint has the legal authority to make treatment decisions if you are unable to decide for yourself.

Appointing an agent lets you control your medical treatment by: • Allowing your agent to make health care decisions on your behalf as you would want them decided; • Choosing one person to make health care decisions because you think that person would make the best decisions; • Choosing one person to avoid conflict or confusion among family members and/or significant others.

You may also appoint an alternate agent to take over if your first choice cannot make decisions for you.

Q. Who can be a health care agent?

A. Anyone 18 years of age or older can be a health care agent. The person you are appointing as your agent or your alternate agent cannot sign as a witness on your Health Care Proxy form.

Q. How do I appoint a health care agent?

A. All competent adults, 18 years of age or older, can appoint a health care agent by signing a form called a Health Care Proxy. You don’t need a lawyer or a notary, just two adult witnesses. Your agent cannot sign as a witness. You can use the form printed here, but you don’t have to use this form.

Q. When would my health care agent begin to make health care decisions for me?

A. Your health care agent would begin to make health care decisions after your doctor decides that you are not able to make your own health care decisions. As long as you are able to make health care decisions for yourself, you will have the right to do so.

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Q. What decisions can my health care agent make?

A. Unless you limit your health care agent’s authority, your agent will be able to make any health care decision that you could have made if you were able to decide for yourself. Your agent can agree that you should receive treatment, choose among different treatments and decide that treatments should not be provided, in accordance with your wishes and interests. However, your agent can only make decisions about artificial nutrition and hydration (nourishment and water provided by feeding tube or intravenous line) if he or she knows your wishes from what you have said or what you have written. The Health Care Proxy form does not give your agent the power to make non-health care decisions for you, such as financial decisions.

Q. Why do I need to appoint a health care agent if I’m young and healthy?

A. Appointing a health care agent is a good idea even though you are not elderly or terminally ill. A health care agent can act on your behalf if you become even temporarily unable to make your own health care decisions (such as might occur if you are under general anesthesia or have become comatose because of an accident). When you again become able to make your own health care decisions, your health care agent will no longer be authorized to act.

Q. How will my health care agent make decisions?

A. Your agent must follow your wishes, as well as your moral and religious beliefs. You may write instructions on your Health Care Proxy form or simply discuss them with your agent.

Q. How will my health care agent know my wishes?

A. Having an open and frank discussion about your wishes with your health care agent will put him or her in a better position to serve your interests. If your agent does not know your wishes or beliefs, your agent is legally required to act in your best interest. Because this is a major responsibility for the person you appoint as your health care agent, you should have a discussion with the person about what types of treatments you would or would not want under different types of circumstances, such as: • Whether you would want life support initiated/continued/removed if you are in a permanent coma; • Whether you would want treatments initiated/continued/removed if you have a terminal illness; • Whether you would want artificial nutrition and hydration initiated/withheld or continued/withdrawn and under what types of circumstances.

Q. Can my health care agent overrule my wishes or prior treatment instructions?

A. No. Your agent is obligated to make decisions based on your wishes. If you clearly expressed particular wishes or gave particular treatment instructions, your agent has a duty to follow those wishes or instructions unless he or she has a good-faith basis for believing that your wishes changed or do not apply to the circumstances.

Q. Who will pay attention to my agent?

A. All hospitals, nursing homes, doctors and other health care providers are legally required to provide your health care agent with the same information that would be provided to you and to honor the decisions made by your agent as if they were made by you. If a hospital or nursing home objects to some treatment options (such as removing certain treatment), they must tell you or your agent BEFORE or upon admission, if reasonably possible.

Q. What if my health care agent is not available when decisions must be made?

A. You may appoint an alternate agent to decide for you if your health care agent is unavailable, unable or unwilling to act when decisions must be made. Otherwise, health care providers will make health care decisions for you that follow instructions you gave while you were still able to do so. Any instructions that you write on your Health Care Proxy form will guide health care providers under these circumstances.

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Q. What if I change my mind?

A. It is easy to cancel your Health Care Proxy, to change the person you have chosen as your health care agent or to change any instructions or limitations you have included on the form. Simply fill out a new form. In addition, you may indicate that your Health Care Proxy expires on a specified date or if certain events occur. Otherwise, the Health Care Proxy will be valid indefinitely. If you choose your spouse as your health care agent or as your alternate, and you get divorced or legally separated, the appointment is automatically cancelled. However, if you would like your former spouse to remain your agent, you may note this on your current form after your divorce or legal separation and date it or complete a new form naming your former spouse.

Q. Can my health care agent be legally liable for decisions made on my health?

A. No. Your health care agent will not be liable for health care decisions made in good faith on your behalf. Also, he or she cannot be held liable for costs of your care just because he or she is your agent.

Q. Is a Health Care Proxy the same as a living will?

A. No. A living will is a document that provides specific instructions about health care decisions. You may put such instructions on your Health Care Proxy form. The Health Care Proxy allows you to choose someone you trust to make health care decisions on your behalf. Unlike a living will, a Health Care Proxy does not require that you know in advance all the decisions that may arise. Instead, your health care agent can interpret your wishes as medical circumstances change and can make decisions you could not have known would have to be made.

Q. Where should I keep my Health Care Proxy form after it is signed?

A. Give a copy to your agent, your doctor, your attorney and any other family members or close friends you want. Keep a copy in your wallet or purse or with other important papers, but not in a location where no one can access it, like a safe deposit box. Bring a copy if you are admitted to the hospital, even for minor surgery, or if you undergo outpatient surgery.

Q. M ay I use the Health Care Proxy form to express my wishes about organ and/or tissue donation?

A. Yes. Use the optional organ and tissue donation section on the Health Care Proxy form and be sure to have the section witnessed by two people. You may specify that your organs and/or tissues be used for transplantation, research or educational purposes. Any limitation(s) associated with your wishes should be noted in this section of the proxy.

Failure to include your wishes and instructions on your Health Care Proxy form will not be taken to mean that you do not want to be an organ and/or tissue donor.

Q. Can my health care agent make decisions for me about organ and/or tissue donation?

A. Yes. As of August 26, 2009, your health care agent is authorized to make decisions after your death, but only those regarding organ and/or tissue donation. Your health care agent must make such decisions as noted on your Health Care Proxy form.

Q. Who can consent to a donation if I choose not to state my wishes at this time?

A. It is important to express your wishes about organ and/or tissue donation to your health care agent, the person designated as your agent, if one has been appointed, and your family members. New York State Law provides a list of individuals who are authorized to consent to organ and/or tissue donation on your behalf.

They are listed in order of priority: your health care agent; your spouse (if you are not legally separated) or your domestic partner; a son or daughter 18 years of age or older; either of your parents; a brother or sister 18 years of age or older; or a guardian appointed by a court prior to your death.

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Health Care Proxy Form Instructions Item (1): Write the name, home address and telephone number of the person you are selecting as your agent.

Item (2): If you want to appoint an alternate agent, write the name, home address and telephone number of the person you are selecting as your alternate agent.

Item (3): Your Health Care Proxy will remain valid indefinitely unless you set an expiration date or condition for its expiration. This section is optional and should be filled in only if you want your Health Care Proxy to expire.

Item (4): If you have special instructions for your agent, write them here. Also, if you wish to limit your agent’s authority in any way, you may say so here or discuss with your health care agent. If you do not state any limitations, your agent will be allowed to make all health care decisions that you could have made, including the decision to consent to or refuse life-sustaining treatment.

If you want to give your agent broad authority, you may do so right on the form. Simply write: I have discussed my wishes with my health care agent and alternate and they know my wishes including those about artificial nutrition and hydration.

If you wish to make more specific instructions, you could write one or all of the following: • If I become terminally ill, I do/don’t want to receive the following types of treatment: • If I am in a coma or have little conscious understanding, with no hope of recovery, then I do/don’t want the following types of treatments: • If I have brain damage or a brain disease that makes me unable to recognize people or speak and there is no hope that my condition will improve, I do/don’t want the following types of treatments: • I have discussed with my agent my wishes about ____________ and I want my agent to make all decisions about these measures.

Examples of medical treatments about which you may wish to give your agent special instructions are listed below (not a complete list): • Artificial respiration • Artificial nutrition and hydration (nourishment and water provided by feeding tube) • Cardiopulmonary resuscitation (CPR)

• Antipsychotic medication • Electric shock therapy • Antibiotics

Item (5): You must date and sign this Health Care Proxy form. If you are unable to sign yourself, you may direct someone else to sign in your presence. Be sure to include your address.

Item (6): You may state wishes or instructions about organ and/or tissue donation on this form. A health care agent cannot make a decision about organ and/or tissue donation because the agent’s authority ends upon your death. The law does provide for certain individuals in order of priority to consent to an organ and/or tissue donation on your behalf: your spouse, a son or daughter 18 years of age or older, either of your parents, a brother or sister 18 years of age or older, a guardian appointed by a court prior to the donor’s death or any other legally authorized person.

Item (7): Two witnesses 18 years of age or older must sign this Health Care Proxy form. The person who is appointed your agent or alternate agent cannot sign as a witness.

Member Services: 1-800-353-3765 (TTY/TDD 711) 8 a.m.–8 p.m., 7 days a week 6323 Seventh Avenue, Brooklyn NY, 11220 www.elderplan.org 84

Health Care Proxy Form (1) I, ______________________________________________________________________________________ Patient Name HEREBY APPOINT ______________________________________________________________________________________ Full Name ______________________________________________________________________________________ Home Address and Telephone Number as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise. This proxy shall take effect only when and if I become unable to make my own health care decisions.

(2) OPTIONAL: ALTERNATE AGENT If the person I appoint is unable, unwilling or unavailable to act as my health care agent, I hereby appoint ______________________________________________________________________________________ Full Name ______________________________________________________________________________________ Home Address and Telephone Number as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise.

(3) UNLESS I REVOKE IT OR STATE AN EXPIRATION DATE OR CIRCUMSTANCES UNDER WHICH IT WILL EXPIRE, THIS PROXY SHALL REMAIN IN EFFECT INDEFINITELY. (Optional: If you want this proxy to expire, state the date or conditions here.)

This proxy shall expire (specify date or conditions): ______________________________________________________________________________________ ______________________________________________________________________________________ (4) OPTIONAL: I DIRECT MY HEALTH CARE AGENT TO MAKE HEALTH CARE DECISIONS ACCORDING TO MY WISHES AND LIMITATIONS, AS HE OR SHE KNOWS OR AS STATED BELOW. (If you want to limit your agent’s authority to make health care decisions for you or to give specific instructions, you may state your wishes or limitations here.)

I direct my health care agent to make health care decisions in accordance with the following limitations and/or instructions (attach additional pages as necessary): ______________________________________________________________________________________ ______________________________________________________________________________________ In order for your agent to make health care decisions for you about artificial nutrition and hydration (nourishment and water provided by feeding tube and intravenous line), your agent must reasonably know your wishes. You can either tell your agent what your wishes are or include them in this section. See instructions (page 67) for sample language that you could use if you choose to include your wishes on this form, including your wishes about artificial nutrition and hydration.

Member Services: 1-800-353-3765 (TTY/TDD 711) 8 a.m.–8 p.m., 7 days a week 6323 Seventh Avenue, Brooklyn NY, 11220 www.elderplan.org White Copy: To Office

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Health Care Proxy Form continued (5) YOUR IDENTIFICATION (please print) __________________________________________________________________________________________ Full Name __________________________________________________________________________________________ Address __________________________________________________________________________________________ Signature Date (6) OPTIONAL: ORGAN AND/OR TISSUE DONATION I hereby make an anatomical gift, to be effective upon my death, of: (check any that apply) q Any needed organs and/or tissues

q The following organs and/or tissues:

__________________________________________________________________________________________ q Limitations: __________________________________________________________________________________________ If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will not be taken to mean that you do not wish to make a donation or prevent a person, who is otherwise authorized by law, to consent to a donation on your behalf. __________________________________________________________________________________________ Signature Date (7) STATEMENT BY WITNESSES (Witnesses must be 18 years of age or older and cannot be the health care agent or alternate.)

I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence. _________________________________________ Date

_________________________________________ Date

Name of Witness 1

Name of Witness 2

_________________________________________ Print

_________________________________________ Print

_________________________________________ Address

_________________________________________ Address

_________________________________________ Signature

_________________________________________ Signature

Member Services: 1-800-353-3765 (TTY/TDD 711) 8 a.m.–8 p.m., 7 days a week 6323 Seventh Avenue, Brooklyn NY, 11220 www.elderplan.org White Copy: To Office

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SECTION 4

Benefit Advisor Tools

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Scope of Appointment Confirmation Form The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

Please initial below the type of product you want the agent to discuss.

(Please refer to the back of this page for the product type descriptions) q

Medicare Advantage Plans (Part C)

By signing this form, you agree to a meeting with a sales agent to discuss the types of product you checked above.

Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment plan.

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

BENEFICIARY OR AUTHORIZED REPRESENTATIVE SIGNATURE AND SIGNATURE DATE Signature_____________________________________ Signature Date:_______________________________________ If you are the authorized representative, please sign above and print below: Representative’s Name:_________________________ Relationship to Beneficiary:_____________________________ To be Completed by Agent: Agent Name _______________________________________________ Phone _________________________________ Beneficiary Name: __________________________________________ Phone _________________________________ Beneficiary Address (optional) _________________________________________________________________________ Date: _________ Initial Method of Contact: _____________________ q Indicate here if beneficiary was a walk-in Plan(s) the agent represented during this meeting: ______________________________________________________ Date Appointment Completed: __________________ Agent’s Signature: _____________________________________

[Plan Use Only:] *Scope of Appointment documentation is subject to CMS record retention requirements * Agent: If the form was signed by the beneficiary at time of appointment, provide explanation why SOA was not documented prior to meeting by completing below section. q

Beneficiary approached Community Outreach Vehicle requesting information

q

Beneficiary approached agent at marketing location requesting information

q

Beneficiary approached agent at sales event requesting information

q

Beneficiary walked into office

q Other: _________________________________________________________________________________________

H3347_EP16151_Accepted

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Scope of Appointment Confirmation Form continued Elderplan is an HMO plan with a Medicare and Medicaid contract. Enrollment in Elderplan depends on contract renewal.

Product Descriptions Medicare Health Maintenance Organization (HMO) —A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).

Medicare Point of Service (HMO-POS) Plan — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. POS plans have network doctors and hospitals but you can also use out-of-network providers for certain benefits, at a higher cost sharing.

Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions.

ATTN: Benefit Advisors Fax Form To: (718) 759-5332 92

White Copy: To Office

Yellow Copy: To Member

Translator / Witness Statement INSTRUCTIONS: This statement must be completed and submitted with the enrollment application when someone other than the enrollee verifies enrollment for the circumstances listed below.

Enrollee Name: ______________________________________________________________________________________ Medicare ID#:_______________________________________________________________________________________ I, ____________________________________________, have witnessed the sales presentation / enrollment for enrollee named above in the capacity of: Check appropriate box: q Non-English Speaking I am fully competent in the _____________________________ and English languages and have understood and translated the documentation for the enrollee. To the best of my knowledge, the enrollee understands the benefits of the plan as well as the conditions of enrollment. q Hearing, Speech, or Visually Impaired, or Illiterate As a neutral party involved in this process, I verify that I (check one): q Participated in (for hearing or speech impaired) OR q Witnessed (for visually impaired or illiterate) The enrollee has indicated to me that he/she understands the coverage provided, together with the conditions of enrollment.

Printed Name of translator/witness ___________________________________________________________________ Signature of translator/witness _______________________________________________________________________ Relationship to Enrollee_________________________________________________ Date _______________________ Address of translator/witness and phone number _______________________________________________________ ___________________________________________________________________________________________________ Signature of Enrollee ____________________________________________________ Date ______________________ Elderplan Benefit Advisor Name _______________________________________________________________________ Signature of Benefit Advisor ______________________________________________Date _______________________

ATTN: Benefit Advisors Fax Form To: (718) 759-5332 H3347_EP16153_Accepted

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Benefit Advisor Checklist

(To be filled out by your Benefit Advisor)

Elderplan wants to ensure that the enrollment process for our members goes as smoothly as possible. Please make sure these steps are completed.

Step 1: q Ensure the following forms have been correctly filled out: q Scope of Appointment (page 91) q Attestation of Eligibility (page 51) q Authorization for Access to Patient Information (page 67) q Witness/Translator Form (if applicable) (page 93) q Individual Enrollment Request Form—(page 55) with special attention to the following areas: • All enrollee personal information: First and last name, address, date of birth and telephone number.

Please ensure name is printed as it appears on enrollee Medicare card.

• Medicare Insurance Information: Copy Medicare claim number and effective dates from enrollee Medicare card.

• Premium payment option is selected if applicable.

• Primary Care Physician (PCP) from Elderplan’s network has been chosen: You can assist enrollee by browsing current network providers by visiting www.elderplan.org and clicking on “Find a Provider” or by calling Sales Operations at (718) 759-4646. Make sure enrollee’s initials are on the line provided next to the selection.

• Application is signed and dated.

Step 2: q Send the information to Elderplan for processing. All the information above can be mailed to:

ATTN: Elderplan Member Operations 6323 Seventh Avenue 3rd FL Brooklyn, NY 11220 OR FAXED TO: (718) 759-5332

ATTN: Benefit Advisors Fax Form To: (718) 759-5332 H3347_EP16957_C

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For more information, call us toll-free

1-800-353-3765 8 a.m.– 8 p.m., 7 days a week.

TTY/TDD users should call

711 Visit our website

Elderplan.org

Elderplan is an HMO plan with Medicare and Medicaid contracts. Enrollment in Elderplan depends on contract renewal. Anyone entitled to Medicare Parts A and B may apply. Enrolled members must continue to pay their Medicare part B premium if not otherwise paid for under Medicaid.