Understanding Your Provider Network
Know Your Options Before You Get Care
Elderplan Plus Long-Term Care is an (HMO-POS D-SNP) plan. This means you have access to an in-network group of doctors, specialists, hospitals, and other providers — plus a Point-of-Service (POS) option that gives you extra flexibility in certain situations.
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
Elderplan Plus Long-Term Care brings your Medicare, your Medicaid and your long-term care services together in one plan. Most members pay $0 for covered 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.
Medical Costs
- Copays for covered medical services: $0 for doctor visits, hospital stays, lab work, emergency care, and long-term care services.
- Part B (medical) Deductible: $0 if you get Medicare cost-sharing help from Medicaid. Otherwise, $283.
- Maximum Out-of-Pocket (MOOP): $9,850. Because Medicaid pays your share of costs, you don’t pay toward this amount.
To pay $0, follow plan rules, like using network providers when required and getting approval for services that need it.
Frequently Asked Questions
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
- Have not opted out of Medicare
In short: 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.
What is a deductible, and do I have to pay it?
A deductible is the amount you pay for covered medical services before our plan starts to pay. You pay it to your doctor or other provider when you get care.
For Elderplan Plus Long-Term Care, the Part B deductible is $283. If you get Medicare cost-sharing help from Medicaid, you pay $0.
Your drug Coverage has a separate deductible. If you get Extra Help from Medicare, you pay $0. If you do not get Extra Help, you pay $700.
What is the maximum out-of-pocket (MOOP), and why don’t I pay toward it?
The maximum out-of-pocket is the most you would pay in a year for covered medical services. Medicare requires all plans to have this limit. For Elderplan Plus Long-Term Care, it is $9,850.
Because Medicaid pays your share of costs, 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
Important Reminders
About Your Provider Network
Always show your Elderplan Member ID card.
Show your Elderplan Member ID card every time you receive covered services.
Confirm network status before every visit.
Before your visit, confirm that your provider is still in-network through the Find a Doctor search tool or by calling Member Services.
You cannot be balance-billed.
Out-of-network providers who accept Medicare cannot bill you for more than what Original Medicare allows. If you receive a bill you believe is incorrect, contact Member Services.
Using POS Option
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 an overview of the list of services that require prior authorization or check the full list in your Evidence of Coverage.