How Your Doctor Network Works
Understanding Your Provider Network
Original Medicare covers doctor visits and outpatient care. Elderplan Select (HMO-POS I-SNP/IE-SNP) adds the convenience of coordinated care, predictable copays, and a Point-of-Service (POS) option that provides added flexibility to receive certain covered services from out-of-network providers.
Your Provider Network at a Glance
How It Works
| What your network includes | How to access it |
|---|---|
| A large network of doctors, hospitals, and facilities for most of your care. | Search the Provider & Pharmacy Directory at elderplan.org, or call Member Services at 1-800-353-3765 (TTY: 711) to find or confirm a provider. |
| A Primary Care Provider (PCP) who gets to know you and coordinates your care. | Choose an in-network PCP — your first stop for most health needs. Member Services can help you pick one. |
| Specialists for focused care when you need it. | Most specialists don’t need a referral. A few do — your PCP will arrange it for you.* |
| Emergency & urgent care when you need care right away. | Go to the nearest emergency room or urgent care, anywhere in the U.S. No referral needed. |
| Telehealth visits from where you live. | Call your in-network provider to set up a phone or video visit — with your PCP, a specialist, urgent care, or mental health care. |
| Added flexibility outside the network (your POS option). | For certain covered services, you can see Medicare-certified providers outside the network. Your cost may be different. |
Understanding Your Costs
Medical Costs
- Copays for covered medical services:
- $0 for primary care visits, nurse practitioner and physician assistant visits, and lab work and X-rays
- $45 for each specialist visit
- $40 for each urgent care visit
- $115 for each emergency room visit. You pay $0 if you’re admitted to the hospital within 24 hours.
- Hospital stays: $320 a day for days 1 to 6. Then $0 a day.
- Part B (medical) deductible: $0
- 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.
To keep your costs low, follow plan rules, like getting a referral or approval for services that need it.
FAQs
Do I have to pay a deductible?
A deductible is the amount you pay for covered services before our plan starts to pay.
For medical services, Elderplan Select has no deductible. You pay $0 for the Part B (medical) deductible.
For prescription drugs, it depends on the drug tier:
- $0 for Tier 1, 2, and 3 drugs
$350 for Tier 4 and 5 drugs. You pay the full cost of these drugs until you’ve paid $350. Then you pay your regular copay.
If you get Extra Help from Medicare, you may pay less.
What is the maximum out-of-pocket (MOOP)?
The maximum out-of-pocket is the most you will pay in a year for covered medical and hospital services. For Elderplan Select, it is $9,850. Your copays count toward this amount.
Once you reach $9,850, you pay $0 for covered medical and hospital services for the rest of the year. The limit does not include your drug costs. Drugs have their own yearly limit: after $2,400, you pay $0 for covered Part D drugs.
What do I pay for a stay in a skilled nursing facility?
For each benefit period, you pay:
- $0 a day for days 1 to 20
- $221 a day for days 21 to 100
- All costs after day 100
Important reminders
About Your Provider Network
Check that your provider is in our network
Our plan covers care from providers in our Provider and Pharmacy Directory. Before your visit, check that your provider is in our network.
You can see some providers outside our network
Elderplan Select includes a point-of-service (POS) option. This means you can receive certain services from providers outside our network, as long as they accept Medicare and haven’t opted out of Medicare. Always check with the provider first.
Out-of-network providers can’t treat you except in an emergency or urgent situation.
Some services need a referral or approval
For some services, like specialist visits and X-rays, you may need a referral. Other services, like hospital stays and skilled nursing care, need approval from our plan first. See the list of services that require prior authorization, or check your Evidence of Coverage.