Advantage for Nursing Home Residents
(HMO-POS I-SNP)
Welcome to Elderplan Advantage for Nursing Home Residents (HMO-POS I-SNP)
Annual Notice of Change
General FAQs
Does this plan pay for my nursing home bill?
No. Your plan pays for your medical care. It does not pay the nursing home’s charges for your room, your meals, or your daily personal care.
Here is what the plan does pay for while you live in the nursing home:
- Visits with your primary care provider ($0)
- Visits with specialists
- Hospital stays and emergency care
- Lab work, X-rays, and other tests
- Physical, occupational, and speech therapy
- Medical equipment and supplies
Your prescription drugs
Your room and board is usually paid for by Medicaid, you or your family or long-term care insurance. If you are not sure how your room and board is being paid, ask the nursing home’s business office or social worker.
What extra benefits do I get, and how do I use them?
Your plan gives you extra benefits that Original Medicare does not. You use most of them with a prepaid card the plan sends you. Some of the extra benefits you can expect may include:
- Money for everyday health items. You can buy things like pain relievers, vitamins, bandages, and toothpaste.
- Rides to health appointments. You can take a taxi, a rideshare, a bus or subway, a van, or medical transport.
- Allowances toward eye exams and eyeglasses
Can I continue to see my current doctors and specialists?
You can choose from Elderplan’s network of primary care doctors and specialists. You generally do not need approval from your primary care provider before seeing a specialist. Some out-of-network care may also be available depending on the service and your plan’s coverage rules. Before receiving care outside the Elderplan network, check your Evidence of Coverage or contact Member Services to understand what is covered and what you may have to pay.
What’s Included with Your Plan
Your plan includes a care team to help you stay healthy. You get a nurse practitioner (NP) or physician assistant (PA). They work with your doctors to make a care plan just for you. At Elderplan, your Coverage is designed to support your health and well-being and help you access the care and services you need in your nursing home.
This section provides a clear overview of your benefits (the services and programs available to you) and your Coverage (how, when, and to what extent those benefits are provided).
Benefits at a Glance
Routine Doctor Visits
Benefits
Get the routine medical care you need from primary care providers, specialists, nurse practitioners and physician assistants, in person or through telehealth.
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior authorization |
|---|---|---|---|
| Primary care provider (PCP) Office visits or telehealth |
$0 per office visit $0 per telehealth visit |
$0 per office visit | May be required for remote patient monitoring devices |
| Specialist Office visits or telehealth |
20% of the cost per office visit 20% of the cost per telehealth visit |
20% of the cost per office visit | A referral may be needed. Approval may be required for remote patient monitoring devices. |
| Care team visits (Nurse practitioner or physician assistant) | 20 % of the cost per visit | 20% of the cost per visit | A referral may be needed |
Tests, Imaging, & Outpatient Care
Benefits
Get the tests and imaging your doctor needs to help diagnose, monitor and manage your health
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior authorization |
|---|---|---|---|
| Lab services | $0 | Same as in-network | Not needed |
| Diagnostic tests, procedures & X-rays | 20% per service | Same as in-network | Required only for PET, MRI, MRA and CT scans |
| Therapeutic radiology Such as radiation treatment for cancer. |
$0 | Same as in-network | May be required |
| Outpatient hospital & ambulatory surgical center | 20% per service | Same as in-network | A referral may be needed |
| Cardiac & pulmonary rehabilitation |
20% | Not covered | Required |
| Dialysis | $0 | Not covered | Not needed |
Mental Health
Benefits
Your plan covers care for your mental health. This includes hospital stays and visits with a therapist or psychiatrist, alone or in a group. Some visits can also be done by video or phone (telehealth). You may need approval from our plan first.
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior authorization |
|---|---|---|---|
| Inpatient mental health care (hospital stay) | $1,736 deductible each benefit period, then: Days 1–60: $0 per day Days 61–90: $434 per day Days 91 and beyond: $868 per lifetime reserve day After lifetime reserve days: you pay all costs |
Required | |
| Outpatient mental health care (individual or group sessions) | 20% of the cost for each session | 20% of the cost for each session | |
| Outpatient psychiatric services (individual or group sessions) | 20% of the cost for each session | 20% of the cost for each session |
Hospital and Emergency
Benefits
Get the routine medical care you need from primary care providers, specialists and physician assistants, in person or through telehealth.
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior authorization |
|---|---|---|---|
| Inpatient hospital
Costs are per benefit period, which starts the day you’re admitted. |
$1,736 deductible each benefit period, then $0 per day for days 1–60,
$434 per day for days 61–90, and $868 per lifetime reserve day for days 91–150 After 150 days, you pay all costs. |
Same as in-network | Required |
| Emergency care Covered anywhere in the U.S. |
20% of the cost, up to $115 per visit. Waived if you’re admitted within 24 hours for the same condition. | Same as in-network | Not needed |
| Urgent care Also available in-network by telehealth. |
$0 per visit | Same as in-network | Not needed |
| Home health care
Part-time skilled nursing, home health aide, and therapy at home
|
$0 | Same as in-network | May be required |
Recovery & Rehab
Benefits
These benefits help you get stronger and recover after an illness, injury, or hospital stay. You need approval from our plan before you get any of these services.
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior authorization |
|---|---|---|---|
| Skilled nursing facility (SNF) care
Up to 100 days per benefit period. You must have a 3-day hospital stay first. |
Days 1–20: $0 per day Days 21–100: $217 per day Days 101 and beyond: you pay all costs |
Required | |
| Physical therapy, occupational therapy, and speech therapy | 20% of the cost | Required | |
| Pulmonary (lung) rehabilitation | 20% of the cost | Require |
Prescription Drugs
Benefits
Drugs you fill at the pharmacy, plus drugs a provider gives you (like infusions). Insulin is capped at $35 for a one-month supply.
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior authorization |
|---|---|---|---|
| Part D drugs Drugs you fill at the pharmacy. |
You pay 25% of the cost for all covered drugs after the $700 Part D deductible. Insulin is capped at $35 for a one-month supply. Maximum out-of-pocket is $2,400 |
Not covered, except in limited situations. | Some drugs |
| Part B drugs Drugs a provider gives you, like infusions. |
20% of the cost. Part B insulin is capped at $35. |
Not covered | Some drugs |
Dental, Vision, & Hearing
Benefits
Get Coverage for dental, hearing and vision care to help you maintain your overall health and quality of life.
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior authorization |
|---|---|---|---|
| Dental Preventive dental care is not covered. |
20% for Medicare-covered comprehensive dental. | Not covered | May be required |
| Vision Includes routine eye exam and eyewear allowance. |
20% for Medicare-covered eye exams. $0 for one pair of glasses or contacts after cataract surgery. Plus up to $150 per year for routine exams and eyewear through your Flex Card. |
Same cost for Medicare-covered exams | Not needed |
| Hearing Routine hearing aids are not a separate benefit — you can use your OTC allowance to buy them. |
20% for Medicare-covered hearing exams. | Same cost for Medicare-covered exams | Not needed |
Preventive Services
Benefits
Our plan covers care to help you stay healthy and find problems early. This includes your yearly wellness visit, cancer screenings, other health screenings, and shots like flu and COVID-19 vaccines. You pay $0 for most preventive services, whether you see a doctor in or out of our network.
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior authorization |
|---|---|---|---|
| Screenings & wellness Yearly wellness visit, cancer screenings (mammograms, colonoscopies), diabetes screenings, and vaccines (flu, COVID-19, pneumococcal, hepatitis B). |
$0 | Same as in-network | Not needed |
Transportation
Benefits
We help you get to your health care visits. This includes ambulance rides and rides to your doctor or therapy visits
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior authorization |
|---|---|---|---|
| Ambulance | 20% of the cost for each one-way trip | ||
| Transportation (rides to care) By taxi, rideshare, bus/subway, van, or medical transport |
$0 for unlimited one-way trips to medical and therapeutic locations, up to $1,000 every 3 months |
Medical Equipment & Supplies
Benefits
Benefit text (required)
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior authorization |
|---|---|---|---|
| Durable medical equipment (DME) Like wheelchairs or oxygen. |
$0 | Not covered | Required for certain items |
| Prosthetic devices Artificial limbs or braces. |
$0 | Not covered | Required |
| Medical supplies | 20% | Not covered | Required |
| Diabetic supplies Test strips and meters are limited to Abbott and Ascensia. |
20% | Not covered | May be required |
OTC & Flexible Spending Allowances
Benefits
Monthly OTC allowance toward health-related items and additional spending alternatives.
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior authorization |
|---|---|---|---|
| Over-the-counter (OTC) items | $175 per month on your OTC card. | N/A | Not needed |
| Flexible Spending Alternative
Loaded on your OTC Card |
Transportation (plan approved)
Up to $1,000 every 3 months |
||
| Acupuncture & alternative therapy
Up to $250 per quarter |
Not needed |
Additional Plan Notes
- Medicaid cost-sharing. This plan is for people who have both Medicare and Medicaid, so your Medicaid Coverage may pay some or all of your Medicare cost-sharing. Show both your Elderplan card and your Medicaid card each time you get services.
- Out-of-network care. This is an HMO-POS plan so that you can see out-of-network providers for many services. Except in an emergency or other urgent situation, out-of-network providers are not required to treat you.
- Prior approval and referrals. Some services require plan approval before you receive them, and others require a referral. The “Prior approval” column shows this at a glance. For full rules, see your Evidence of Coverage or call Member Services.
- You must renew your Medicaid Coverage every year. Need help with your Medicaid application or renewal? Get Medicaid Support
- Leaving Elderplan Advantage for Nursing Home Residents: This plan is your choice. You can leave whenever you want. Learn more about disenrolling from your Elderplan plan.
Extras
Therapeutic Leave
Therapeutic leave covers overnight stays away from your skilled nursing facility (SNF) or assisted living facility (ALF) where you currently reside.
Learn More
Supervised Exercise Therapy (SET)
Supervised Exercise Therapy (SET) is for members with Peripheral Artery Disease (PAD) who experience leg pain while walking. The program uses guided exercise sessions to help improve walking ability, reduce symptoms, and support better circulation.
Learn More
Companion Care
For eligible members with certain chronic conditions (SSBCI).
$0 for up to 104 hours per year, in 4-hour blocks.
Your OTC & Extra Allowances
Your Elderplan Advantage for Nursing Home Residents (HMO-POS I-SNP) includes an OTC benefit that gives you money on a prepaid card to spend on eligible health and wellness items you use every day. Your plan also includes additional allowances to help with certain health-related expenses, such as transportation, vision care and more.
Eligible members may have access to more. If you have a qualifying chronic condition, your OTC benefit may expand to cover additional everyday needs and expenses, including healthy foods, home-delivered meals, hearing aids and more.
$175 every month for eligible health items
Learn more about your flexible spending allowances
Get Care with Elderplan Advantage for Nursing Home Residents (HMO-POS I-SNP)
Everything you need to get the most out of your Elderplan Advantage for Nursing Home Residents (HMO-POS I-SNP) plan — all in one place.
Always show both your Elderplan Member ID card and your Medicaid card every time you receive covered services, fill a prescription, or visit a provider.
