Get an Additional Level of Support Wherever You Call Home
For Medicare beneficiaries who live in one of Elderplan’s contracted assisted living communities, nursing homes, or congregate care settings.
Provides an additional level of care from a skilled Nurse Practitioner (NP) or Physician Assistant (PA) along with a dedicated Registered Nurse (RN)
Available in the Bronx, Manhattan, Brooklyn, Queens, and Richmond, plus Nassau, Suffolk, Dutchess, Monroe, Orange, Putnam, Rockland, Westchester, Ontario, Orleans, Seneca, Yates, and Livingston counties.
Our Care Network
Our network includes over Specialists, Primary Care Doctors, Pharmacies and More!
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 |
|---|---|---|---|
| Care team visits (nurse practitioner or physician assistant) | $0 | $0 | May be required |
| Primary care (PCP)
Office visits or telehealth |
$0 copay per visit | $0 copay per visit
|
Not needed |
| Specialist
Office visits or telehealth. |
$45 copay per visit
|
$45 copay per visit
|
A referral may be needed |
| Nurse Practitioner & Physician Assistants | $0 copay | $0 copay | Referral may be required |
| Routine Podiatry | $10 per visit | $10 per visit | Up to 6 visits per year, in- and out-of-network combined |
Tests and Imaging
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 |
|---|---|---|---|
| PET, MRI, MRA | $75 Copay
|
$75 Copay | Required |
| Labs, diagnostic tests, X-rays | $0 copay | $0 copay | Required |
| CT Scans | $0 | $0 copay
|
Required |
| Radiation Therapy | $85 Copay | $85 Copay | No |
Mental Health Care
Benefits
Mental Health
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior Authorization |
|---|---|---|---|
| Inpatient mental health care | Per admission: $250 copay each day for days 1–6. $0 copay each day from day 7 on.
|
Not Covered | Required |
| Outpatient mental health care: Individual and group sessions | $50 copay per session. Also available by telehealth. Call your provider for details. | $50 copay per session | Required |
| Psychiatric services: Individual and group sessions | $55 copay per session. Also available by telehealth. Call your provider for details. | $55 copay per session
|
Required |
Hospital and Emergency
Benefits
Get the care you need when you’re seriously ill, injured or need immediate medical attention, including hospital stays and emergency services.
Coverage
| Benefit | In-network Cost | Out-of-network Cost | Prior Authorization |
|---|---|---|---|
| Emergency Room | $115 waived if admitted within 24 hours | $115 waived if admitted within 24 hours | No |
| Ambulance | Ground $115/trip; air 20% | Ground $115/trip; air 20% | Authorization is required for non-emergency services and ground |
| Inpatient Hospital | $320/day for days 1-6, then $0. | $320/day for days 1-6, then $0. | Yes |
| Outpatient Hospital | $175 | $175 | No |
| Ambulatory Surgical Center | $100 | $100 | Referral may be required |
Recovery and Rehab
Benefits
Get the care and support you need to recover, regain strength and maintain your independence after an illness, injury or hospital stay.
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior Authorization |
|---|---|---|---|
| Skilled nursing facility | $0 for days 1–20; $221/day for 21–100; full cost after 100 | Not covered | Yes (no prior hospital stay needed) |
| Home Health | $0 | $0 | Yes, must be homebound |
| Physical and Speech Therapy | $55/visit | $55/visit | Yes |
| Occupational Therapy | $35/visit | $35/visit | Yes |
| Cardiac Pulmonary Rehab | Cardiac $30 (intensive $40); pulmonary $25 | Not Covered | Yes |
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 | Deductible: $0 for Tier 1, 2 and 3 drugs. $350 for Tier 4 and 5 drugs.
Then, for a 1-month supply: Tier 1: $0. Tier 2: $2. Tier 3: $25. Tier 4: $100. Tier 5: 29% of the cost. Insulin: no more than $35 for a 1-month supply. |
Not Covered | Some drugs |
| Part B | 20% of the cost. Part B insulin: up to $35. | May be required for certain drugs. Some drugs require step therapy (trying another drug first). | |
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 |
|---|---|---|---|
| Medicare-covered dental | 20% coinsurance | Not Covered | |
| Supplemental Dental- Preventative and Comprehensive | $0 copay up to $1,950 annual allowance | Not Covered | No |
| Vision Care (Medicare & Routine) | $0 copay for Medicare exams & post-cataract
$0 copay for routine exam and eyewear up to $150 per year |
In-Network Only | No |
| Medicare Covered Hearing | $0 copay for Medicare-covered hearing exams
$0 copay for diagnostic hearing services and hearing aids and $1,000 annual allowance |
In-network only for hearing | No |
Preventive Services
Benefits
Screenings & wellness
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior Authorization |
|---|---|---|---|
| Annual wellness visit, cancer screenings (mammograms, colonoscopies), smoking cessation, and vaccines (flu, COVID-19). | $0 copay for Medicare-covered preventative services to in-network cost-share | $0 copay for Medicare-covered preventative services | Not needed |
Transportation
Benefits
Getting to medical and therapeutic places.
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior approval |
|---|---|---|---|
| Ground ambulance | $115 copay per one-way trip | Needed only for rides that are not emergencies | |
| Air ambulance | 20% of the cost per one-way trip | ||
| Rides to your appointments:
Unlimited one-way rides to medical and therapeutic places by taxi, ride-share, bus, subway, van or medical transport |
Covered up to $1,000 every 3 months | Prepaid allowance used at approved retailers. |
OTC and Flexible Spending Allowances
Benefits
Monthly OTC allowance toward health-related items and additional spending alternatives toward dental and vision.
Coverage
| Benefit | In-network cost | Out-of-network cost | Prior approval |
|---|---|---|---|
| Over-the-counter (OTC) items | $175 per month | N/A | Not needed |
| Flexible Spending Alternative Loaded on your OTC Card. |
Dental Up to $1,950 per year. |
N/A | Not needed |
| Vision (routine) Up to $150 per year. |
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| Transportation (plan-approved) Up to $1,000 every 3 months. |
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| Acupuncture, chiropractic & alternative therapy $250 every three months |
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.
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