Understanding Your Provider Network

Know Before You Get Care

Elderplan for Medicaid Beneficiaries is an HMO-POS plan. This means, in addition to in-network providers, you have a Point-of-Service (POS) option that gives you additional flexibility in certain situations. Think of the POS option as a safety net that broadens your choice of providers for certain services — so you’re not limited to only in-network doctors the way you would be with a traditional HMO.

Your Provider Network at a Glance

Four key things to know about your network

1. Use Our Network for Most of Your Care As an HMO-POS plan, you have a network of doctors, hospitals and other health care providers available to you. Your plan also includes a (POS) option that gives you some flexibility to receive certain covered services from outside the Elderplan network.	2. Choose a Primary Care Provider (PCP) As an Elderplan member, you will need to choose an in-network Primary Care Provider. Your PCP helps coordinate your care and is often the doctor you see first when you need medical care.
3. No Referrals Needed for Specialists You do not need a referral from your PCP to see a specialist in-network or out-of-network.	4. Most Members Pay $0 for Medical Care Because you have both Medicare and Medicaid, Medicaid typically pays your Medicare deductibles, copayments, and coinsurance. Most members pay [$0] for all covered core medical care.

Understanding Your Costs

If you get Medicare cost-sharing help from Medicaid, you pay $0 for covered medical services. That’s because Medicaid pays your share of Medicare costs, like deductibles and copays. Your drug costs depend on whether you get Extra Help from Medicare.

Copays for covered medical services: $0 for doctor visits, hospital stays, lab work, and emergency care if you get Medicare cost-sharing help from Medicaid. Otherwise, you may pay up to 20% of the cost for some services.
Part B (medical) deductible: $0 if you get Medicare cost-sharing help from Medicaid. Otherwise, $283.
Hospital deductible: $0 if you get Medicare cost-sharing help from Medicaid. Otherwise, $1,736 each benefit period.
Maximum out-of-pocket (MOOP): $9,850. If you get Medicare cost-sharing help from Medicaid, you don’t pay toward this amount.

Home care, personal care, and some other services are covered by Medicaid, not by this plan. Use your Medicaid card for these services

Frequently Asked Questions

What Is Medicare Cost Sharing?

Cost sharing is what you pay when you get care. It includes deductibles, copays, and coinsurance.

Some people with Medicaid get help paying these Medicare costs. This help can also pay your Medicare Part A and Part B premiums. If you get this help, you pay $0 for covered medical services in our plan and $0 for your monthly plan premium.

What is the Point-of-Service (POS) option?

The “POS” in HMO-POS D-SNP stands for Point-of-Service. It’s an extra benefit that offers a little more flexibility in choosing doctors than a standard HMO plan.

The POS option lets you receive certain covered services from out-of-network providers, meaning doctors or facilities that don’t have a contract with Elderplan. To qualify, the provider must be:

- Medicare-certified, and

- Has not opted out of Medicare

Important things to keep in mind:

- Not every service is covered out-of-network under the POS option; only specific services listed in your Evidence of Coverage are covered.

- Your cost share may be different when you use an out-of-network provider.

- For anything not covered under the POS option, you’ll still need to use in-network providers (except in emergencies, at urgent care when the network isn’t available, or for out-of-area dialysis).

What is a deductible, and do I have to pay it?

A deductible is the amount you pay for covered services before our plan starts to pay. You pay it to your doctor, hospital, or other provider when you get care.

If you get Medicare cost-sharing help from Medicaid, you pay $0 for your medical deductibles. Otherwise, you pay:

$283 for the Part B (medical) deductible
$1,736 for the hospital deductible, each benefit period

Your drug Coverage has a separate deductible. If you get Extra Help from Medicare, you pay $0. If you don’t get Extra Help, you pay $700.

What is the maximum out-of-pocket (MOOP), and do I pay toward it?

The maximum out-of-pocket is the most you would pay in a year for covered medical and hospital services. Medicare requires all plans to have this limit. For Elderplan for Medicaid Beneficiaries, it’s $9,850.

If you get Medicare cost-sharing help from Medicaid, you don’t pay toward this amount. The limit does not include your plan premium or your drug costs. Drugs have their own yearly limit: after $2,400, you pay $0 for covered Part D drugs.

Senior woman talking on her phone while using a laptop

Important Reminders

About Your Provider Network

Show your Elderplan Member ID card

Every time you receive covered services. Do not use your red, white, and blue Medicare card for covered medical services while you are a member of this plan.

Confirm network status before every visit.

Provider networks can change. Before your visit, confirm that your provider is still in-network through the Find a Doctor search tool.

Check the POS status before seeing out-of-network providers.

If you plan to use your POS option, always confirm with the provider that they accept Medicare and have not opted out — otherwise, your care may not be covered.

Some Services Require Prior Authorization.

Before you receive certain services, Elderplan must approve them. You can view the list of services that require prior authorization or check the Medical Benefits Chart in Chapter 4 of your Evidence of Coverage. To learn more about prior authorization and what to expect, visit Getting Approval for Care.