Receive Enhanced Care in a Nursing Home
For Medicare beneficiaries or dual Medicare and Medicaid beneficiaries living in one of Elderplan’s contracted nursing homes.
Provides an additional level of care; a skilled Nurse Practitioner (NP) or Physician Assistant (PA) who will support and guide you by working with your physicians to create a customized care plan.
Available in the Bronx, Manhattan, Brooklyn, Queens, and Staten Island, plus Nassau, Suffolk, Dutchess, Monroe, Orange, Putnam, Rockland, Westchester, Ontario, Orleans, Seneca, Yates, and Livingston counties.
Our Care Network
Our network includes over 40,000 Specialists, Primary Care Doctors, Pharmacies and Dentists!
Benefits Overview
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 |
Plan Documents
How to Enroll
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Learn More by PhoneFor more information about this plan, call Elderplan: 1-844-642-4115 [TTY: 711]
8 a.m. to 8 p.m., 7 days a week.
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Make an AppointmentTo confirm eligibility, make an appointment with a benefits advisor.
Footnotes
Common Plan & Coverage Questions
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