How Your Doctor Network Works
Understanding Your Provider Network
Original Medicare covers doctor visits and outpatient care. Elderplan Advantage for Nursing Home Residents (HMO-POS I-SNP) adds a dedicated care team that comes to you where you live, coordinated care, and a Point-of-Service (POS) option that gives you added flexibility to get certain covered services from Medicare-certified providers outside the network.
Four Key Things to Know About Your Network
| 1. Use our network for most of your care | 2. Get care where you live |
|---|---|
| As an HMO-POS plan, you have a network of doctors, hospitals, and other providers. Your plan also includes a point-of-service (POS) option. This lets you get certain covered services from providers outside our network, as long as they accept Medicare and have not opted out. Out-of-network providers don’t have to treat you, except in an emergency or urgent situation. | Your plan includes a nurse practitioner or physician assistant who works with your doctors to create a care plan. They can do checkups, help manage ongoing health conditions, order lab tests, and write prescriptions. |
| 3. You may need a referral | 4. Know your costs |
| You may need a referral to see a specialist, a nurse practitioner or a physician assistant or to get X-rays. Some services also need approval from our plan first. | You pay $0 for primary care visits and 20% of the cost for specialist visits. Your yearly costs for covered medical services are limited to $9,850. |
Understanding Your Costs
Medical Costs
- Copays for covered medical services:
- $0 for primary care visits and lab work
- $0 for urgent care visits
- 20% of the cost for specialist visits, nurse practitioner and physician assistant visits, and X-rays
- 20% of the cost, up to $115, for each emergency room visit. You pay $0 if you’re admitted to the hospital within 24 hours.
- Hospital stays: $1,736 deductible each benefit period. Then $0 a day for days 1 to 60, and $434 a day for days 61 to 90. †
- Part B (medical) deductible: $283 †
- Maximum out-of-pocket (MOOP): $9,850. Once you pay this much for covered medical services in a year, you pay $0 for covered medical services for the rest of the year.
† These are 2026 amounts and may change for 2027. We will post updated amounts at www.elderplan.org when they are released.
To keep your costs low, follow plan rules, like getting a referral or approval for services that need it.
Coverage Rules: When Services Require Prior Authorization
Some services require plan approval before you receive them. This is called prior authorization. In most cases, you get prior authorization through your PCP or specialist. Your doctor contacts the plan’s Prior Authorization Department to talk about the care you need, and the plan then tells you and your doctor the decision. You can view the full list of services that require prior authorization, or refer to your Medical Benefits Chart (Chapter 4 of your Evidence of Coverage) for details about your Coverage. For more information about how the process works, visit our Getting Approval for Care section.