Footnotes

¹ You must continue to pay your Medicare Part B premium unless paid for by the state medical assistance program.

² References in this document to brand and generic drugs are based on a pharmacy benefit that must be ordered from the plan formulary. Co-payments may apply and vary based on use of in- or out-of-network pharmacies and your yearly out-of-pocket drug costs. Please contact Elderplan for additional details.

³ With Elderplan Classic Zero Premium (HMO), the maximum co-payment per in-network medically necessary benefit period is $875. A benefit period begins the day you go to a hospital or skilled nursing facility. A benefit period ends when you have not received hospital or skilled nursing care for 60 consecutive days. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital co-payment for each benefit period. There is no limit to the number of benefit periods you can have.

⁴ You must use plan providers except in emergent or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers, neither Medicare nor Elderplan will be responsible for the costs.

⁵ The products and services described are neither offered nor guaranteed under our contract with the Medicare program.  In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the Elderplan grievance process.

⁶ Dental, vision and hearing in-network preventive benefits are available in Elderplan Classic Zero Premium (HMO) and Elderplan Extra Help (HMO).

⁷ Elderplan for Medicaid Beneficiaries (HMO SNP) is a Dual Eligible Special Needs Plan, available to Medicare beneficiaries who receive NYS Medicaid or other assistance through New York State medical assistance programs. Premiums, co-pays, co-insurance and deductibles may vary based on the level of Extra Help that you may receive. Please contact the plan for further details.

⁸ Members in plans with this benefit may purchase over-the-counter (OTC) non-prescription drugs as well as health-related items from a catalog of eligible OTC items provided by Elderplan. The benefit is quarterly and does not carry over from one quarter to the next.

⁹ Members who are eligible to enroll in this plan must have chronic health care needs, require care management, and be eligible for a nursing home level of care, but prefer and are able to live at home and have full Medicaid.

¹⁰ Anyone entitled to Medicare Parts A and B, living in Brooklyn, Manhattan, Queens, Staten Island, the Bronx, Westchester County or Nassau County, eligible for full Medicaid. Elderplan Advantage for Nursing Home Residents (HMO SNP) and Elderplan Plus Long-Term Care (HMO SNP) members are entitled to Medicare Parts A and B in the above service areas with the addition of Monroe County.

¹¹ You must continue to pay your Medicare Part B premium unless paid for by the state medical assistance program.

¹² References in this document to brand and generic drugs are based on a pharmacy benefit that must be ordered from the plan formulary. Co-payments may apply and vary based on use of in- or out-of-network pharmacies and your yearly out-of-pocket drug costs. Please contact Elderplan for additional details.

¹³ You must use plan providers except in emergent or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers, neither Medicare nor Elderplan will be responsible for the costs.

¹⁴ Members in plans with this benefit may purchase over-the-counter (OTC) non-prescription drugs as well as health-related items from a catalog of eligible OTC items provided by Elderplan. The benefit period is either a month or a quarter depending on the plan. The benefit does not carry over from one quarter to the next or one month to another month depending on a plan.

¹⁵ The products and services described above are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the Elderplan grievance process.

¹⁶ In-network vision and hearing benefits and preventive dental benefits are available in Elderplan Classic Zero Premium (HMO) and Elderplan Extra Help (HMO). In-network comprehensive dental is available in Elderplan Extra Help (HMO) plan.

¹⁷ With Elderplan Classic Zero Premium (HMO), the maximum co-payment per in-network medically necessary benefit period is $1,365. A benefit period begins the day you go to a hospital or skilled nursing facility. A benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital co-payment for each benefit period. There is no limit to the number of benefit periods you can have.

¹⁸ Elderplan for Medicaid Beneficiaries (HMO SNP) is a Dual-Eligible Special Needs Plan, available to Medicare beneficiaries who receive N. Y. S. Medicaid or other assistance through N. Y. S. medical assistance programs. Premiums, co-pays, co-insurance and deductibles may vary based on the level of extra help that you may receive. Please contact the plan for further detail.

Disclaimers

Elderplan has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until 12/31/2013. NCQA’s approval is based on a review of Elderplan Model of Care and is an indicator of compliance with CMS requirements. NCQA’s approval is not an endorsement by CMS and/or NCQA of Elderplan or the quality of service provided by Elderplan. Elderplan will still need to be approved each year by CMS in order to operate. If you have questions regarding our approval by the NCQA, please contact us at 1-800-353-3765.

Elderplan is a health plan with a Medicare contract.  Individuals must have both Part A and Part B to enroll. You must continue to pay your Medicare Part B premium if not otherwise paid for by Medicaid.

Members must receive all routine care from plan providers.

Authorization rules may apply for certain services. Limitations, copayments and restrictions may apply. Members may enroll in Elderplan only during specific times of the year. Contact Elderplan for more information. Plan materials are available in alternative formats or languages.  Please call Elderplan’s Member Services Department at 1-800-353-3765 (TTY 1-800-662-1220 for the hearing impaired), between 8 a.m. – 8 p.m., 7 days a week, to request materials in alternate formats.

Esta información puede estar disponible en diferentes idiomas o formatos. Favor de llamar al  1-800-353-3765 (TTY 1-800-662-1220) de 8:00 AM a 8:00PM, 7 dias a la semana. Si necesita obtener información en otro formato o idioma, comuníquese con el Servicio de Atención al Cliente al número mencionado anteriormente.

Elderplan’s Medicare Prescription Drug benefit is only available to enrolled members. If a beneficiary is already enrolled in a Medicare Advantage Part D (MA-PD) Plan, the enrollee must receive his/her Medicare Prescription Drug benefit through that plan.

Elderplan renews its contract with the Centers for Medicare and Medicaid Services (CMS) annually. Benefits beyond the current contract year are not guaranteed.

Elderplan’s pharmacy network includes retail, mail order, long-term care and home infusion pharmacies. For mail order information and additional information about network pharmacies, contact Elderplan’s Member Services Department at 1-800-353-3765 (TTY 1-800-662-1220 the hearing impaired), between 8 a.m.– 8 p.m., 7 days a week. Information may also be obtained by writing Elderplan, Attention: Member Service Department, 6323 Seventh Ave., 3^rd Floor, Brooklyn, NY 11220-4711.

In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances, and quantity limitations and restrictions may apply.

Medicare beneficiaries may enroll in Elderplan through the CMS Medicare Online Enrollment Center, located at www.medicare.gov. For more information, contact Elderplan’s Member Service Department at 1-800-353-3765 (TTY 1-800-662-1220) for the hearing impaired), between 8 a.m.– 8 p.m., 7 days a week.

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

• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
• The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
• Your State Medicaid Office
• People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs, including monthly prescription drug premiums, annual deductibles and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.