We have provided answers to the most frequently asked questions (FAQ) new members have.
Choose the topic below that best matches your question(s).
For New Members
When will my benefits go into effect?
Most of the time, your benefits will go into effect the first day of the month immediately following the month you joined. For example, if you join in March, your Elderplan benefits will start April 1.
To verify your enrollment effective date, please call Member Services at 1-800-353-3765, or the TTY number for the hearing impaired, 711, available seven days a week, between the hours of 8:00 a.m. and 8:00 p.m.
What if I need to see a doctor, and I don’t have my Elderplan member card yet?
You can bring your welcome letter as proof of insurance to your doctor appointments until you get your member card from us. This letter is also proof of your prescription drug coverage. You should show this letter at the pharmacy until you get your member card from us.
Or you can call Member Services! We can help your doctor confirm your benefits if you need medical care and your Elderplan coverage has started, but your card has not arrived.
What do I do with my Medicare card?
Elderplan has a contract with Medicare to provide you with all of your health benefits. That means you should use Elderplan’s member card for your doctor visits, hospitalization, prescriptions and other medical services. Don’t worry, you are still part of Medicare, but now you receive expanded benefits with Elderplan.
DO NOT USE YOUR MEDICARE CARD. Put your Medicare card in a safe place where you can find it. Do not throw it away.
From now on, your Elderplan member card is the card you need.
Contact Member Services if you did not get an Elderplan member card or if you need a replacement card.
What if I have both Medicare and Medicaid?
You can have Medicare and Medicaid and be an Elderplan member. Here are some important facts to keep in mind:
- As a member, it is your responsibility to assist Elderplan in preparing any required re-certification documents as they are due.
- For some Elderplan plans, we manage a portion of your Medicaid benefits, while the remaining Medicaid benefits are covered under fee-for-service (FFS) Medicaid. Please refer to your Evidence of Coverage for details on how to access your Medicaid benefits and what cards you need to show when you receive service.
- Depending on your plan, providers will either bill FFS Medicaid or Elderplan for Medicaid covered services or cost shares. In order to bill FFS Medicaid for services or cost shares, providers must participate in the Medicaid program with New York State.
- Elderplan Providers who participate in the Medicaid program with NY State will bill Medicaid directly for any applicable Medicaid cost shares depending on the plan. Elderplan providers may bill Elderplan directly for other covered services or may bill Elderplan directly for the entire Medicaid amount depending on the plan.
- You will pay discounted rates for prescription medications if you have both Medicare and Medicaid. These discounts will apply throughout the entirety of your Part D prescription benefit.
About Your Providers
What is a Primary Care Physician (PCP)?
Primary Care Physicians, or PCPs, provide a full range of basic health services. PCPs can be:
- General practitioners
- Family practice physicians
- On occasion, obstetrician/gynecologists
When you become a member of Elderplan, you must choose a plan provider to be your PCP. Your PCP is a physician who meets state requirements and is trained to give you basic medical care. You will get your routine or basic care from your PCP. Your PCP will also coordinate the rest of the covered services you get as a member of Elderplan.
How can I change my Primary Care Physician?
You may change your PCP to another doctor within the Elderplan network at any time. There are two ways you can do this:
- Call the Member Services Department and speak with a representative.
- Mail your request for a new PCP to:
Elderplan Member Services
6323 Seventh Ave.
Brooklyn, NY 11220
Either way, once your request is processed, a new Elderplan member card listing the name of your new PCP will be sent to you.
How do I get care from a specialist?
- All the specialists that you see must be part of the Elderplan network.
- You do not need a referral from your Primary Care Physician (PCP) in order to see a specialist.
- Sometimes you will need prior authorization from Elderplan before receiving certain types of care. In this case, your PCP will contact Elderplan and let you know if and when approval is given.
How do I get a second opinion?
- Contact your PCP.
- Elderplan will need to authorize any request for a second opinion. Your PCP will contact Elderplan for you.
- You must pay any applicable co-payment for a specialist visit when you go for your second opinion. Be sure to pay it before you leave the specialist’s office.
How to get care from out-of-network providers
Elderplan will cover emergency care or urgently needed care from an out-of-network provider; this does not require prior authorization. If you are using the plan’s coverage for your medical services that Medicare requires our plan to cover, and the providers in our network cannot provide this care , you can get this care from an out-of-network provider. For example, kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area, are covered. You must contact us to get authorization prior to seeking this care. Please contact Member Services to obtain any necessary prior authorizations.
Do I need to sign up for a separate Medicare Prescription Drug Plan to receive prescription coverage?
No. As an Elderplan member, you already have this coverage, so there’s no need to sign up for a separate Medicare Prescription Drug Plan. That’s because Elderplan is a Medicare Advantage Part D (MA-PD) plan, which includes the Medicare Prescription Drug Plan. That means we contract with Medicare to provide both comprehensive health care coverage and affordable prescription coverage in one easy plan. So you get all the great benefits of Original Medicare plus a lot more! In fact, you enjoy some of the most generous prescription drug benefits in Greater Metropolitan New York. So don’t listen to others who say you need a separate prescription drug plan. You’re covered!
Please Note: If you sign up for a separate prescription drug plan, you will automatically be disenrolled from Elderplan and will lose not only your generous prescription drug coverage, but all of your great Elderplan benefits.
Can I go to any pharmacy to fill my prescriptions?
No. Generally, benefits are only available at contracted network pharmacies. Normally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. Whenever possible, before you fill your prescriptions at an out-of-network pharmacy, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription.
What is a coverage gap and does Elderplan prescription coverage have one?
Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what members pay for their drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,820. After a member enters the coverage gap, they pay 25% of the plan’s cost for covered brand name drugs and 37% of the plan’s cost for covered generic drugs until their costs total $5,100, which is the end of the coverage gap. Not everyone will enter the coverage gap. After a member’s yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,100 they pay the greater of: 5% of the cost, or $3.40 copay for generic (including brand drugs treated as generic) and a $8.50 copayment for all other drugs.
Elderplan for Medicaid Beneficiaries (HMO SNP) and Elderplan Plus Long-Term Care (HMO SNP) members won’t have to worry about the coverage gap. And, because Low Income Subsidy (LIS) also known as Extra Help pays for your prescriptions throughout the coverage gap, you only pay nominal prescription drug co-payments no matter how many medications you take.
With Elderplan Advantage for Nursing Home Residents (HMO SNP) and Elderplan Extra Help (HMO), there is a coverage gap unless you are receiving Low Income Subsidy (LIS) also known as Extra Help
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. TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week. Or call the Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778, or your State Medicaid Office.
Billings and Claims
What should I do if I receive a bill from a laboratory that is not part of the Elderplan network?
All laboratory services must be furnished by an Elderplan contracting laboratory. If your Primary Care Physician has referred you for lab services and you receive a bill, DO NOT PAY IT.
Send it to:
Elderplan Claims Department
P.O. Box 73111
Newnan, GA 30271-3111
If you continue to receive bills or other letters regarding the laboratory service, please contact Member Services immediately.
What happens if a claim is denied?
If you have a claim denied, you may ask Elderplan to reconsider its determination. This is called an “appeal” or “request for reconsideration.”
If you need help in filing your appeal, please call Member Services. When we receive your request for an appeal, we will distribute it to different people other than those who made the determination to deny your claim. This helps ensure your request gets fair reconsideration.
What is the difference between emergency and urgent care?
Urgent care is needed when your medical condition does not place you in serious jeopardy but could get worse and care is immediately needed. If you are in the Elderplan service area and need urgent care, call your Primary Care Physician (PCP).
Urgent care may be provided when you are outside the Elderplan service area. You may visit a walk-in clinic or doctor’s office for urgent care. If you are admitted to the hospital within one day for the same condition, you do not pay any cost sharing for the urgent care visit.
Emergency care is needed when the onset of your condition is sudden and severe, and the absence of immediate medical attention could place you in serious jeopardy. You may go to any emergency room if you reasonably believe you need emergency care. There is a co-payment or co-insurance for the visit, but you do not pay this amount if you are admitted to the hospital within one day for the same condition.
What if I need urgent or emergency care when traveling outside the country?
Urgent care is only covered in the USA. Emergency care is covered worldwide.
Who pays for prescription drugs I receive in the hospital?
While you’re in the hospital, Elderplan pays all your prescription drug costs. Plus, we’ll pay for small amounts of prescription drugs to “carry you over” until you get home and start using your personal supply again.
Can my doctor visit me in the hospital?
Maybe. Doctors can only visit patients in hospitals where they are on staff or have what are called “visiting privileges.”
Usually, this is not a problem because Elderplan must approve your planned hospitalizations before you receive treatment.
If there is an emergency, and you are taken to a hospital outside our network or where your doctor can’t visit you, you can contact your Primary Care Physician, and he or she can help coordinate your care.
What if you are billed directly for the full cost of services and items covered by Elderplan?
Providers should only bill Elderplan for the cost of your covered services and items. If a provider sends you a bill instead of sending it to Elderplan, you can send it to us to pay. You should not pay the bill yourself. But if you do, Elderplan may pay you back.
If you have any questions, please call:
The call is free.
How do I get care during a state of disaster or emergency?
If the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from Elderplan.
During a declared disaster, we will allow you to get care from out-of-network providers at no cost to you. If you cannot use a network pharmacy during a declared disaster, you will be able to fill your prescription drugs at an out-of-network pharmacy.
Potential for Possible Contract Termination
If Elderplan leaves the Medicare program, by contract termination, or is no longer available in your area because of a service area reduction, we will provide you with a termination notice or plan change notice, well in advance. This notice will provide information about Medicare coverage options available to you because of the plan change, including guaranteed Medigap rights.
Whether leaving the plan is your choice or not, you can find more information about your Medicare choices after you leave and the rules that apply in the Evidence of Coverage.