2022 Sales Presentation Binder

2022

Sales Presentation Binder Elderplan is an HMO plan with Medicare and Medicaid contracts and has a coordination of benefits agreement with the New York State Department of Health.

Enrollment in Elderplan depends on contract renewal. Anyone entitled to Medicare Part A and B may apply. Enrolled members must continue to pay their Medicare Part B premium if not otherwise paid by Medicaid or a third party.

Elderplan renews its contract with the Centers for Medicare & Medicaid Services (CMS) annually. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Benefits, premiums and/or co-payments/co-insurance may change on January 1st of each year. This information is not a complete description of benefits. Please contact Elderplan for details.

H3347__EP17112_M 2022 Sales Binder

Are You Eligible For One Of Elderplan’s Products?

4 Do you have Medicare Parts A and B? 4 Do you live in NYC, Dutchess, Nassau, Orange, Putnam, Rockland or Westchester counties for more than six months during the year?

4 Do you have Medicaid coverage from the State of New York?

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About Elderplan

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About Elderplan 4 Elderplan is a not-for-profit health plan founded right here in New York more than 35 years ago. Our primary objective is ensuring that members of our community receive the care and support they deserve.

4 Elderplan offers a variety of Medicare Advantage plans tailored to fit the changing needs of Medicare and dual Medicare and Medicaid beneficiaries at every level of health.

4 Elderplan is a member of MJHS Health System. Founded in 1907 by Four Brooklyn Ladies, MJHS has a rich history of caring for at-risk New Yorkers with compassion, dignity, and respect. Elderplan is proud to care for people of every race, ethnicity, faith, national origin, gender identity or expression, sexual orientation, or military status.

4 Includes more than 176,997 provider locations in our network.

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3

Elderplan has a range of Medicare Advantage plans designed to meet the needs of our members.

Let’s discuss your current coverage and needs!

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Finding the right plan for you: The following questions will help us determine which plan will best fit your needs:

4 Do you have Medicaid?

4 Do you qualify for Low Income Subsidy?

4 Are low co-payments to see your regular doctor important to you?

4 Are low co-payments to see your specialists important to you?

4 Are low co-payments for prescription drugs important to you?

4 Is supplemental comprehensive dental important to you?

4 Is assistance with Long-Term Care services at home important to you?

4 Is transportation to your doctor’s appointments important to you?

4 What other things are important to you in a health plan?

Based on what you have told me today, I believe plan name would be the best fit for you.

It offers you the benefits you want in a health plan and even more.

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5

Our Plans - Highlights 4 Elderplan for Medicaid Beneficiaries (HMO D-SNP): A plan designed for people with Medicare who are also receiving financial help from the state (Medicaid, Medicare Savings Program) to help pay for the cost of health care coverage. This plan helps manage medical, hospital and prescription drug benefits under one umbrella. Your medical expenses will be covered at little to no cost to you and you have minimal cost-sharing for prescriptions. Plus, you will enjoy an over-the-counter (OTC) benefit, which includes health-related and select grocery items that you can purchase at a store or order online, as well as home delivered meals. The plan also includes comprehensive dental, transportation to medical appointments and Brain Games with BrainHQ®.

4 Elderplan Plus Long-Term Care (HMO D-SNP): This plan was designed for Medicare and Medicaid beneficiaries who need valuable assistance with Long-Term Care at home. You’ll be happy to know that there is no plan premium, no co-payments for doctor and hospital visits, and low co-payments for prescription drugs. Plus, you will enjoy an over-the-counter (OTC) benefit, which includes health-related and select grocery items that you can purchase at a store or order online, as well as home delivered meals. The plan also provides transportation to medical appointments and Brain Games with BrainHQ®.

4 Elderplan Extra Help (HMO): A plan designed for Medicare beneficiaries that was created to offer a little extra help in paying for your health coverage. You get the health care you need with a low premium and low co-pays. In addition to medical and hospital coverage, our members with Low Income Subsidy (LIS) will also experience additional savings on prescription drug coverage. Plus, you will enjoy an over-the-counter (OTC) benefit, which includes health-related and select grocery items you can purchase at a store or order online, as well as home delivered meals. The plan also provides comprehensive dental, transportation to medical appointments and Brain Games with BrainHQ®.

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Important Information • Medicare beneficiaries may enroll in Elderplan only during specific times of the year.

• Elderplan/HomeFirst complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

• ATTENTION: If you speak a non-English language or require assistance in ASL, language assistance services, free of charge, are available to you. Call 1-800-353-3765 (TTY 711) • Elderplan / Homefirst cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

• ATTENTION: If you speak a non-English language or require assistance in ASL, language assistance services, free of charge, are available to you. Call 1-800-353-3765 (TTY: 711).

• Elderplan / Homefirst cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

• ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-353-3765 (TTY: 711).

• Elderplan / HomeFirst 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年 齡、殘障或性別而歧視任 何人。注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-353-3765（TTY:711） • This information is available in different formats. Please call member services at the number listed above if you need plan information in another format or language.

• Esta información esta disponible en diferentes idiomas o formatos, entre ellos en español, en letra grande o en cinta de audio. Si necesita obtener información en otro formato o idioma, comuníquese con el Servicio de Atención al Cliente al número que se menciona anteriormente.

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Important Information About Our Plans • Network Lock-in: You must use network providers except in emergency or urgent care situations or for out-of-area dialysis. If you obtain routine care from out-of-network providers neither Medicare nor Elderplan will be responsible for the costs. An exception to this rule is for a member with full Medicaid who may receive other services (not available in Elderplan) through Medicaid Fee for Service (FFS) using your Medicaid card.

— Out-of-network/non-contracted providers are under no obligation to treat Elderplan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask the plan for prior approval before you receive the service. If you don’t receive prior approval, Elderplan may not pay for the service and in some cases the provider will bill you. Please call member services or see your Evidence of Coverage for more information.

• Inpatient Benefit Period: A benefit period begins the day you are admitted as an inpatient (hospital or skilled nursing facility) and ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital co-payment for each benefit period. There is no limit to the number of benefit periods you can have.

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Important Information About Our Plans • Pharmacy Network: Elderplan’s pharmacy network includes standard retail, mail-order, long-term care and home infusion pharmacies. In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances and quantity limitations (restrictions may apply). For mail-order information and additional information about network pharmacies, contact Elderplan’s Member Services Department at 1-800-353-3765 (TTY 711). For Elderplan Plus Long-Term Care Plan call (1-877-891-6447). Hours are 8 am to 8 pm, 7 days week.

— Information may be obtained by visiting Elderplan’s website at www.elderplan.org or in writing to Elderplan: Elderplan Attention: Member Services Department 6323 Seventh Avenue Brooklyn, NY 11220-4711 • Dual Eligibles: Premiums, co-pays, co-insurance and deductibles may vary based on the level of help you receive from Medicaid. You should contact the plan for further details or call New York State Department of Health (Social Services) HRA Medicaid Helpline at 1-888-692-6116 between 8 am and 5 pm, Monday through Friday. TTY 711.

• Extra Help: You may be able to get Extra Help to pay for prescription drug premiums and costs. To see if you qualify for Extra Help, call: — 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day / 7 days a week.

— The Social Security Office 1-800-772-1213 from 7 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778.

— Medicaid Office 1-718-557-1399 from 8 am to 5 pm, Monday through Friday.

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What Are My Medicare Choices?

Original Medicare

A

+

Hospital

A Hospital

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+

+

B

D Stand-alone Drug Plan

Medical

Part A: Hospital • Inpatient hospital • Skilled Nursing • Home health • Hospice care

+

Prescription Drug Coverage

Part B: Medical • Doctor visits • Outpatient rehab • Urgent care • Durable medical equipment • Outpatient hospital • Lab tests & X-rays

Part D: Prescription Drugs Helps cover the cost of prescription drugs

Medicare Advantage

B Medical

+

+ Additional Benefits

+

D

Prescription Drugs

Prescription Drug Payment Stages Up to $480

$4430

$7050

Low cost

STAGE 1: DEDUCTIBLE STAGE

STAGE 2: INITIAL COVERAGE STAGE

STAGE 3: COVERAGE GAP STAGE

STAGE 4: CATASTROPHIC STAGE

You pay co-pays or coinsurance for your drugs after you have met your deductible.

You pay 25% coinsurance for generic drugs and 25% for brand name drugs during this stage.

Your plan pays its share for covered drug costs and you pay your share.

Not everyone will reach the coverage gap.

Once you and others on your behalf have spent $7050 in drug costs, you pay $3.95 co-pay for generic drugs and $9.85 co-pay for brand name drugs or 5% coinsurance of retail costs, whichever is higher for the duration of the year.

If you select a plan with a deductible, you pay the full cost of your drugs until you have paid your deductible. No Medicare drug plan may have a deductible more than $480 in 2022.

Some plans work best with Low Income Subsidy which will reduce the cost sharing (co-payments or co-insurance).

You stay in this stage until the total cost of drugs paid by both you and the plan reaches $4430.

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You stay in this stage until you (or others on your behalf) have spent a total of $7050 on your drug costs.

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NY State Pharmaceutical Assistance Program The Elderly Pharmaceutical Insurance Coverage (EPIC) program supplements Medicare Part D drug coverage for greater annual benefits and savings. When purchasing prescription drugs, show both the EPIC and Medicare Part D drug plan cards at the pharmacy. After the Medicare Part D deductible is met, drug costs not covered by Part D (including co-payments/co-insurance) can be submitted to EPIC for payment. You will pay an EPIC co-payment ranging from $3 to $20 based on the cost of the drug.

EPIC can provide: • A Medicare Special Enrollment Period (SEP) so that a new member may enroll in a Part D drug plan at any time during the year; • A Medicare one-time plan change per calendar year for existing members; • Medicare Part D drug plan premium assistance; • Co-payment assistance after the Medicare Part D deductible is met, if the member has one. EPIC also covers approved Part D-excluded drugs once a member is enrolled in a Part D drug plan.

Please note that EPIC deductible members must first meet their EPIC deductible before they will pay EPIC co-payments. This is in addition to meeting their Medicare Part D drug plan deductible should their Part D plan have one. For more information, please visit https://www.health.ny.gov/health_care/epic/ 12

NY State Pharmaceutical Assistance Program To join EPIC, you must: • Be a New York State resident age 65 or older • Have an annual income below $75,000 if single or $100,000 if married – Fee plan eligibility $0-$20,000 single $0-$26,000 married – Deductible plan eligibility $20,001-$75,000 single $26,001-$100,000 married • Be enrolled or eligible to be enrolled in a Medicare Part D plan (no exceptions), and • Not be receiving full Medicaid benefits.

Note: You can join EPIC at any time during the year. Once enrolled, you will receive a ‘Special Enrollment Period’ to join a Medicare Part D drug plan. You are not eligible to receive EPIC benefits until you are enrolled in a Part D drug plan.

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NY State Pharmaceutical Assistance Program Fee Plan Members • EPIC annual fees range from $8 – $300 based on your previous year’s income.

• EPIC pays the Part D monthly drug plan premiums up to the average cost of a basic Medicare drug plan, $42.27 per month in 2021.

• EPIC co-payments range from $3 to $20 based on the cost of the drug.

• Members will only pay EPIC co–payments for Part D and EPIC covered drugs after the Part D deductible, if any, is met. Members will pay EPIC co–payments for Part D excluded drugs.

• Bills are mailed quarterly for EPIC fee plan members.

• Members with full “Extra Help” from Medicare will continue to have their EPIC fees waived.

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NY State Pharmaceutical Assistance Program Deductible Plan Members • EPIC deductibles range from $530 – $3,215 based on the previous year’s income.

• EPIC pays the monthly Part D drug plan premiums up to the average cost of a basic Part D drug plan for members with income up to $23,000 single and $29,000 married.

• After you meet your EPIC deductible, you will only pay the EPIC co-payments ranging from $3 to $20 based on the cost of your drug.

• Members with higher incomes must pay their Medicare Part D premiums each month. Their EPIC deductible will be lowered by the annual cost of a basic Part D plan (approximately $480) to help them pay.

• After you meet any Part D deductible if you have one, out-of-pocket drug costs for covered Part D and EPIC medications will be applied to your EPIC deductible.

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NY State Pharmaceutical Assistance Program EPIC Co-payments At the pharmacy, seniors present both their EPIC and Medicare Part D drug identification to their pharmacist. The EPIC co-payment is based on the cost of the prescription remaining after billing the Medicare Part D drug plan.

Co-payments for approved drugs purchased after any Medicare Part D deductible is met or for approved Part D – excluded drugs

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PRESCRIPTION COSTS (AFTER SUBMITTED TO MEDICARE)

EPIC CO-PAYMENT

Up to $15

$3

$15.01 to $35

$7

$35.01 to $55

$15

Over $55

$20

NY State Pharmaceutical Assistance Program Income For purposes of your EPIC enrollment, household gross income is the previous year’s total annual income for the member or married spouses. It includes, but is not limited to: • Federal adjusted gross household income as reported on your income tax return • Social Security payments (less Medicare premiums) • Railroad retirement benefits • The taxable amount of IRA distributions and retirement annuities • Support money, including foster care support payments • Supplemental Security income • Tax-exempt interest • Worker’s compensation • Gross amount of loss-of-time insurance • Cash public assistance and relief, other than medical assistance for the needy • Non-taxable strike benefits • Veterans’ disability pensions • Lottery winnings 10

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NY State Pharmaceutical Assistance Program Income not included: • Food stamps • Medicare premiums • Medicaid • Scholarships • Grants • Surplus food • Payments made to veterans under the federal Veterans’ Dioxin and Radiation Exposure Compensations Standards Act (Agent Orange) • Payments made to individuals because of their status as victims of Nazi persecution

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Part D Late Enrollment Penalty (LEP) The late enrollment penalty is an amount added to your Medicare Part D monthly premium.

You may owe a late enrollment penalty if you go without Part D or creditable prescription drug coverage for any continuous period of 63 days or more after your Initial Enrollment Period for Part D coverage is over.

How much is the Part D penalty?

• The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage.

• Medicare calculates the penalty by multiplying 1% of the “national base beneficiary premium” ($33.06 in 2021) times the number of full, uncovered months you didn’t have Part D or creditable coverage. The monthly penalty is rounded to the nearest $0.10 and added to your monthly Part D premium.

• The national base beneficiary premium may increase each year, so your penalty amount may also increase each year.

If you get Extra Help, you don’t pay the late enrollment penalty.

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Calculating the Part D Late Enrollment Penalty Example: Mrs. Martinez is currently eligible for Medicare, and her Initial Enrollment Period ended on May 31, 2017. She doesn’t have prescription drug coverage from any other source.

She didn’t join by May 31, 2017, and instead joined during the Open Enrollment Period that ended December 7, 2019. Her drug coverage was effective January 1, 2020.

Since Mrs. Martinez was without creditable prescription drug coverage from June 2017– December 2019, her penalty in 2021 was 31% (1% for each of the 31 months) of $33.06 (the national base beneficiary premium for 2021) or $10.25. Since the monthly penalty is always rounded to the nearest $0.10, she paid $10.30 each month in addition to her plan’s monthly premium.

Here’s the math: • .31 (31% penalty) × $33.06 (2021 base beneficiary premium) = $10.25 • $10.25 rounded to the nearest $0.10 = $10.30 • $10.30 = Mrs. Martinez’s monthly late enrollment penalty for 2021 If you get Extra Help, you don’t pay the late enrollment penalty.

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When Can You Enroll?

Initial Coverage Enrollment Period (ICEP):

Annual Enrollment Period (AEP):

Special Enrollment Period (SEP):

Medicare Advantage Open Enrollment Period (MA-OEP)

All year

7 month period that starts 3 months before and ends 3 months after the month of your 65th birthday.

Oct 15th – Dec 7th

During this period you can change your Medicare health plans and prescription drug coverage for the following year to better meet your needs.

Enrollment will take effect January 1st .

All year

You may qualify to change plans based on special circumstances (e.g., you move into a new service area, you qualify for or lose eligibility for Medicaid or Low Income Subsidy).

Jan 1st – Mar 31st

You can disenroll from your current plan and switch to a different Medicare Advantage plan one time only during this period. You can also return to original Medicare and purchase a Medicare supplement (Medigap) plan.

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Let’s Discuss Your Current Coverage • Turning 65 and eligible for Medicare Part A and Part B • Covered through Original Medicare (Medicare Part A and Part B) • Prescription drug (Part D) • Eligible for Medicaid • Financial assistance (e.g., Medicare Savings, LIS, EPIC) • Medicare supplemental insurance (Medigap) • Medicare Advantage plan (Part C) • TRICARE • VA benefits • Employer or union benefits • Current coverage ending soon

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Elderplan For Medicaid Beneficiaries (HMO D-SNP) Making sure you receive the care you need is important to us. Making it easy for you to get that care is important too. We understand that coordinating your Medicare and Medicaid benefits can be challenging. That’s why we created a plan that makes your life a little easier by covering your medical, hospital and prescription drug benefits all under one umbrella.

Your medical expenses will be covered at little-to-no-cost to you and you pay minimal cost-sharing for prescriptions. Plus, you will enjoy an over-the-counter (OTC) benefit, which includes health-related and select grocery items* that you can purchase at a store or order online, as well as meals. The plan also includes comprehensive dental, transportation to medical appointments and Brain Games with BrainHQ®.

*For eligible members (with certain chronic conditions) the Special Supplemental Benefits for the Chronically Ill (grocery benefit) combines with the OTC benefit to cover certain grocery items and meals as a part of the monthly OTC allowance. Eligible members will be notified and provided instructions on how to access the benefit.

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Elderplan For Medicaid Beneficiaries (HMO D-SNP) Special eligibility requirements Enrollment in this plan is designed for people who are eligible for both Medicare and New York State Medicaid or who are part of the Medicare Savings Program (MSP). The Medicaid benefit categories and type of assistance served by our plan are listed below: • Full Benefit Dual Eligible (FBDE): Helps pay Medicare Part A and Part B premiums, and other cost-sharing (like deductibles, coinsurance, and copayments). These individuals are also eligible for full Medicaid benefits.

• Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost sharing (like deductibles, coinsurance, and copayments). (Some people with QMB are also eligible for full Medicaid benefits (QMB+).)

• Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums.

(Some people with SLMB are also eligible for full Medicaid benefits (SLMB+).)

• Qualified Medicare Beneficiary (QMB+): Helps pay Medicare Part A and Part B premiums, and other cost sharing (like deductibles, coinsurance, and copayments). These individuals are also eligible for full Medicaid benefits.

• Specified Low-Income Medicare Beneficiary (SLMB+): Helps pay Part B premiums.

These individuals are also eligible for full Medicaid benefits.

• Qualifying Individual (QI): Helps pay Part B premiums • Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums 24

Elderplan For Medicaid Beneficiaries (HMO D-SNP) BENEFIT

YOU PAY

Part B Deductible

$0 or $203*

PCP Visits

$0 or 20% coinsurance*, in-person and telehealth

Specialists Visits

$0 or 20% coinsurance*, in-person and telehealth No referral needed to see an In-network specialist.

Lab Services/Outpatient Blood Services

$0 co-payment

Diagnostic Tests and Procedures

$0 or 20% coinsurance* $0 or 20% coinsurance*

Diagnostic Radiological Services

Authorization is required only for PET, MRI, MRA, and CT scan.

Therapeutic Radiology Services

$0 or 20% coinsurance*

*If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay $0 25

Elderplan For Medicaid Beneficiaries (HMO D-SNP) Expanded prescription drug coverage with…UNLIMITED* brand name and generic drugs!

BENEFIT

YOU PAY

Part D Premium

$0 or $39.90 monthly plan premium**

Part D Deductible

$0, $99, or $480 per year***

Tier 1 Generic Drugs (including brand drugs treated as generic)

Tier 1 For all Other Drugs

Depending on your “Extra Help” You Pay: $0 co-pay or $1.35 co-pay or $3.95 co-pay or 15% of the cost or 25% of the cost Depending on your “Extra Help” You Pay: $0 co-pay or $4.00 co-pay or $9.85 co-pay or 15% of the cost or 25% of the cost

*You must still order prescriptions from the Elderplan formulary through a plan-affiliated pharmacy. Utilization rules may apply including Authorization, Step Therapy and/or Quantity Limits **If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay $0 ***Depending on your level of “Extra Help” (LIS).

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Elderplan For Medicaid Beneficiaries (HMO D-SNP) BENEFIT

YOU PAY

Hospital Stays

$0* cost-sharing for each benefit period, OR $1,484 deductible Days 1-60: $0 co-payment per day Days 61-90: $371 co-payment per day Days 91 and beyond: $742 co-payment per lifetime reserve day (up to 60 days over your lifetime).

Beyond lifetime reserve days: you pay all costs.

Authorization is required.

These are 2021 cost-sharing amounts and may change for 2022.

Emergency Care

$0 or 20% co-insurance* (up to $90) per visit. (waived if admitted within 24 hours for the same condition)

Urgent Care

$0 or 20% co-insurance* (up to $65) per visit.

Worldwide Emergency/Urgent Care Up to $50,000

$0 cost-sharing

*If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay $0.

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Elderplan For Medicaid Beneficiaries (HMO D-SNP) BENEFIT

YOU RECEIVE

Over-the-Counter (OTC)

$130 Every Month (The OTC card balance cannot be carried over to the next month)

OTC + Grocery + Meals*

$0 cost-sharing The Special Supplemental Benefit for the Chronically Ill (SSBCI) combines the OTC benefit to cover certain grocery items and meals as a part of the monthly OTC allowance.

Post-Discharge Meals

$0 cost-sharing Eligible members will receive 2 prepared meals a day for 14 days after discharge.

Nutritious meals will be delivered directly to your home at no extra cost to you.**

Fitness Benefit (Gym Access) + over 8,000 digital exercise videos available online

$0 cost-sharing

*For eligible members with certain chronic condition. **The meal program is limited to 2 times per calendar year.

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Elderplan For Medicaid Beneficiaries (HMO D-SNP) BENEFIT

YOU PAY

Diagnostic Hearing Exams (Medicare covered)

$0% or 20% coinsurance*

Routine Hearing Exam

$0 co-payment once every 3 years

Routine Hearing Aids

Up to $1,300 for both ears combined, every three years. $0 co-payment for fitting and evaluation every three years (Authorization is required by a Provider or Specialist)

Diagnostic Vision Exams (Medicare covered)

$0% or 20% coinsurance*

Routine Eye Exam

$0 co-payment (one routine eye exam for eyewear every year)

Routine Eyewear

$100 annual maximum per calendar year including contact lenses or eyeglasses (lenses and frames)

Medicare-Covered Eyewear

$0 co-payment for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery

*If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay $0.

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Elderplan For Medicaid Beneficiaries (HMO D-SNP) BENEFIT

YOU PAY

Preventive Care

$0 cost-sharing

Comprehensive Dental (Medicare covered only)

0% or 20% coinsurance*

Supplemental Comprehensive Dental

$375 per quarter (3 months) allowance. Limited to selected service codes.

Diabetic Supplies

$0 cost-sharing

Home Health Care

$0 cost-sharing Authorization is required

Transportation Services

$0 cost-sharing for up to 6 one-way trips You may take up to 6 one-way trips to a plan approved health-related location per quarter (3 months) by Taxi, Bus, Subway, or Van

*If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay $0.

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Why Choose Elderplan For Medicaid Beneficiaries (HMO D-SNP)?

Recap of a few plan highlights: 4 You can choose quality Board-Certified Private Practice Network Providers 4 Low co-pays for prescription drugs 4 You will receive up to $1,560 a year for over the counter (OTC) health-related, select healthy grocery items and meals** 4 Home-delivered meals after you have been discharged from a hospital or nursing home stay 4 Transportation to an Elderplan provider 6 one way trips every 3 months 4 Between Elderplan, Medicare Advantage and State Medicaid, you do not pay for your medical services provided by in-network providers!

4 Health Club Membership with a participating Silver and Fit Health Club, plus over 8,000 digital workouts available online.

4 Elderplan is a not-for-profit organization, reinvesting our earnings to bring you improved benefits and services ** Unused OTC card balance cannot be carried over to the next month. Grocery items and meals for eligible members (with certain chronic conditions)

Q&A / Final Summary of Benefits Review 31

Ready to Join the Elderplan Family?

We just need to complete your enrollment application and you’re all set!

4 Choose your PCP 4 Remember you must use network providers for routine services with the exception of emergency, urgently needed services and out of network dialysis 4 You must also use Elderplan’s pharmacy network which includes standard retail, mail-order, long-term care and home infusion pharmacies.

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Elderplan Cares You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call: 4 The Centers for Medicare and Medicaid Services (CMS) at 1-800-Medicare (1-800-633-4227). TTY/TTD users should call 4 1-877-486-2048, 24 hours a day/7 days a week; 4 The Social Security Administration at 1-800-772-1213 between 7 am and 7 pm, Monday through Friday. TTY/TTD users should call 1-800-325-0778; or the 4 The New York State Medicaid Helpline 1-888-692-6116 (TTY 711) from 8 am to 5 pm Monday through Friday.

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Elderplan Plus Long-Term Care (HMO D-SNP) Receiving the care and support you need in the safety and comfort of your own home is important. This plan was designed for Medicare and Medicaid beneficiaries who need valuable assistance with Long-Term Care at home.

You’ll be happy to know that there is no plan premium, no co-payments for doctor and hospital visits, and low co-payments for prescription drugs. Plus, you will enjoy an over-the-counter (OTC) benefit, which includes health-related and select grocery items that you can purchase at a store or order online, as well as meals. The plan also provides transportation to medical appointments and Brain Games with BrainHQ®.

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Elderplan Plus Long-Term Care (HMO D-SNP) Special eligibility requirements Enrollment in this plan is only for people who are eligible for both Medicare and full New York State Medicaid, need long-term care services, require care management, and are eligible for a nursing home level of care, but prefer and are able to live at home.

Are expected to need one of the following Community Based Long-Term Care Services for more than 120 days: nursing services at home; therapies in the home, home health aide services, personal care services in the home, adult day health care, private duty nursing, or consumer directed personal assistance services.

You are determined eligible for Long-Term care services by Elderplan or an entity designated by the New York State Department of Health using the current NYS eligibility tool.

Please note: If you lose your Medicaid eligibility but can reasonably be expected to regain eligibility within 3-month(s), then you are still eligible for membership in our plan. Your EOC tells you about coverage and cost sharing during a period of deemed continued eligibility. If you do not regain Medicaid eligibility you will be disenrolled after the 3-months. See your EOC for more information.

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Elderplan Plus Long-Term Care (HMO D-SNP) BENEFIT

YOU PAY

Part D Premium

$0 monthly plan premium (Because you are a dual-eligible member with full Medicaid benefits, your plan premium is covered on your behalf)

Primary Care Provider (PCP) Visits

$0 cost-sharing for each visit, in-person and telehealth

Specialist Visits

$0 cost-sharing for each visit, in-person and telehealth No referral needed to see an in-network specialist.

Lab Services, Outpatient Blood Services, Diagnostic Tests and Procedures

$0 cost-sharing

Diagnostic Radiological Services

$0 cost-sharing Authorization is required only for PET, MRI, MRA, and CT scan.

Therapeutic Radiological Services

$0 cost-sharing

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Elderplan Plus Long-Term Care (HMO D-SNP) Expanded prescription drug coverage with…UNLIMITED* brand name and generic drugs!

BENEFIT

YOU PAY

Part D Deductible

$0, $99, or $480 per year**

Tier 1 Generic Drugs (including brand drugs treated as generic)

Depending on your “Extra Help” you pay: $0 co-pay or $1.35 co-pay or $3.95 co-pay or 15% of the cost or 25% of the cost

Tier 1 For all Other Drugs

Depending on your “Extra Help” you pay: $0 co-pay or $4.00 co-pay or $9.85 co-pay or 15% of the cost or 25% of the cost

*You must still order prescriptions from the Elderplan formulary through a plan-affiliated pharmacy. Utilization rules may apply including Prior Authorization, Step therapy and/or Quantity Limits. **Depending on your Extra Help (“LIS”) 37

Elderplan Plus Long-Term Care (HMO D-SNP) BENEFIT

YOU PAY

Hospital Stays

$0 cost-sharing for each benefit period.

Our plan covers 90 days for an Inpatient Hospital Stay.

Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover.

Authorization is required

Emergency Care

$0 cost-sharing for each visit

Urgent Care

$0 cost-sharing for each visit

Worldwide Emergency/Urgent Care Up to $50,000

$0 cost-sharing

Over-the-Counter (OTC)

$195 Every Month (this monthly limited benefit does not carry over from one month to another)

OTC + Grocery + Meals*

For eligible members (with certain chronic conditions) the Special Supplemental Benefits for the Chronically Ill (grocery benefit) combines with the OTC benefit to cover certain grocery items and meals as a part of the monthly OTC allowance.

*For eligible members with certain chronic condition.

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Elderplan Plus Long-Term Care (HMO D-SNP) BENEFIT

YOU PAY

Hearing Services

$0 cost-sharing for Medicare-covered diagnostic hearing exams $0 cost-sharing for Medicaid-covered services Hearing Aid(s) up to $600 per ear with a $1200 maximum every 3 years. Authorization is required for hearing aid(s) by a Provider or Specialist. One year supply batteries included with the purchase and will be shipped with the hearing aid.

Vision Care/Eyewear

$0 cost-sharing for Medicaid covered services

Medicare-Covered Eyewear

$0 cost-sharing for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery

Personal Care Services (Medically necessary ADL and IADL)

$0 cost-sharing

Social and Environmental Support

$0 cost-sharing

Personal Emergency Response Services

$0 cost-sharing

Diabetes Monitoring (Diabetic Supplies)

$0 cost-sharing

Home Health Care

$0 cost-sharing Authorization is required 39

Why Choose Elderplan Plus Long-Term Care (HMO D-SNP)?

Recap of a few plan highlights: 4 Your Medicare and Medicaid benefits will be coordinated through a dedicated Care manager 4 You will receive up to $2,340 a year for over-the-counter health- related, select healthy grocery items and meals ** 4 Non-emergency/medically necessary transportation to and from doctor appointments 4 Between Elderplan, Medicare Advantage and State Medicaid, you do not pay for your medical services provided by in- network providers!

4 Elderplan is a not-for-profit organization, reinvesting our earnings to bring you improved benefits and services **Unused OTC card balance cannot be carried over from month to month. Grocery items and meals for eligible members (with certain chronic conditions)

Q&A / Final Summary of Benefits Review

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Ready to Join the Elderplan Family?

We just need to complete your enrollment application and you’re all set!

4 Choose your PCP 4 Remember you must use in-network providers for routine services with the exception of emergency, urgently needed services and out of network dialysis 4 You must also use Elderplan’s pharmacy network which includes standard retail, mail-order, long-term care and home infusion pharmacies

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Elderplan Cares You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call: 4 The Centers for Medicare and Medicaid Services (CMS) at 1-800-Medicare (1-800-633-4227). TTY/TTD users should call 1-877-486-2048, 24 hours a day/7 days a week; 4 The Social Security Administration at 1-800-772-1213 between 7 am and 7 pm, Monday through Friday. TTY/TTD users should call 1-800-325-0778; or the 4 The New York State Medicaid Helpline 1-800-541-2831 (TTY 711) from 8 am to 5 pm Monday through Friday.

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Elderplan Extra Help (HMO) Making sure you receive the care you need is important to us. Making sure it’s affordable is important too. That’s why we designed a plan for Medicare beneficiaries, which offers a little extra help in paying for your health coverage.

You get the health care you need with a low premium and low co-pays. In addition to medical and hospital coverage, our members with Low Income Subsidy (LIS) will also experience additional savings on prescription drug coverage.

Plus, you will enjoy an over-the-counter (OTC) benefit, which includes health-related and select grocery items you can purchase at a store or order online, as well as meals.

The plan also provides comprehensive dental, transportation to medical appointments and Brain Games with BrainHQ®.

Beneficiaries enrolling in Elderplan Extra Help Medicare Advantage Prescription Drug Plan who do not have Low Income Subsidy will not be eligible for the reduced LIS cost sharing for Part D prescription costs.

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Elderplan Extra Help (HMO) BENEFIT

YOU PAY

Part D Premium

$42.00* monthly plan premium

Primary Care Provider (PCP) Visits

$0 cost-sharing for each visit, in-person and telehealth

Specialist Visits

$35 co-payment for each office visit $10 co-payment for telehealth No referral needed to see an in-network specialist

Lab Services/Outpatient Blood Services

$0 cost-sharing

Diagnostic Tests and Procedures

$35 co-payment

Outpatient X-Rays

$20 co-payment for each X-ray service

Diagnostic Radiological Services

20% coinsurance Authorization is required for PET, MRI, MRA, and CT scan.

Therapeutic Radiological Services

20% coinsurance

Fitness Benefit (Gym Access) + over 8,000 digital exercise videos available online

$0 cost-sharing

*Your plan premium may be lower based on your Extra Help (“LIS”).

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Elderplan Extra Help (HMO) BENEFIT

YOU RECEIVE

Over-the-Counter (OTC)

$60 every quarter (this quarterly limited benefit does not carry over from one month to another)

OTC + Grocery + Meals*

For eligible members (with certain chronic conditions) the Special Supplemental Benefit for the Chronically Ill (SSBCI) combines the OTC benefit to cover certain grocery items and meals as a part of the monthly OTC allowance.

Acupuncture

$0 co-payment per visit.

You may receive up to 20 visits per year.

Transportation

$0 cost-sharing for up to 8 one-way trips per quarter You may take up to 8 one-way trips to a plan approved health-related location per quarter (3 months) by Taxi, Bus, Subway, or Van

*For eligible members with certain chronic condition.

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Elderplan Extra Help (HMO) Expanded Prescription drug coverage with…UNLIMITED*** Brand and Generic drugs!

If you qualify for “Extra Help,” you may not pay the amounts listed in the table below for your Part D prescription drugs. The exact amount you pay may vary depending on the amount of “Extra Help” you receive.

PART D PREMIUM TIERS (TIER NAME)

$42.00 per month MAIL ORDER RETAIL RETAIL DEDUCTIBLE* PHARMACY COST PHARMACY COST PHARMACY COST (90-day supply)** (90-day supply) (30-day supply)^

Tier 1 (Preferred Generic)

$4 co-payment

$12 co-payment

$8 co-payment

$10 co-payment

$30 co-payment

$20 co-payment

Tier 3 (Preferred Brand)

$47 co-payment

$141 co-payment

$94 co-payment

*Tier 4 (Non-Preferred Drug)

$100 co-payment

$300 co-payment

$200 co-payment

25% coinsurance

25% coinsurance

25% coinsurance

Tier 2 (Generic)

*Tier 5 (Specialty Tier)

$0

$480

*The deductible only applies to drugs in Tiers 4 & 5. †NDS – Non-Extended Days Supply. Certain Specialty drugs will be limited up to a 30-day supply per fill. **60-day supply is also available for Standard Retail ***Utilization rules may apply including Prior Authorization, Step therapy and/or Quantity Limits ^One-month supply for Standard retail (in-network), Long-term care (31-day), and Out-of-network cost-sharing 46

Elderplan Extra Help (HMO) BENEFIT

YOU PAY

Hospital Stays

Deductible: $0 Days 1-5: $390 co-payment Days 6 and beyond: $0 co-payment per day Unlimited inpatient days are based on medical necessity Authorization is required

Emergency Care

$90 co-payment per visit If admitted to the hospital within 24 hours for the same condition, there is no cost-sharing.

Urgent Care

$35 co-payment per office visit $10 co-payment for telehealth

Worldwide Emergency/Urgent Care Up to $50,000

$65 co-payment per visit

Ambulance

$215 co-payment each one way trip

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Elderplan Extra Help (HMO) BENEFIT

YOU PAY

Supplemental Preventive Dental^

Limited to select service codes

Supplemental Comprehensive Dental*

Limited to select service codes

Elderplan Extra Help (HMO) also provides: ^Supplemental Preventive Dental coverage is limited to certain dental codes covering oral exams, cleanings, and dental x-rays.

(Please refer to Evidence of Coverage for details or call member services). *Supplemental Comprehensive dental coverage is limited to certain dental codes covering restorative, endodontics, prosthodontic, periodontics and extraction services. (Please refer to Evidence of Coverage for details or call member services).

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Elderplan Extra Help (HMO) BENEFIT

YOU PAY

Diagnostic Hearing Exams (Medicare covered only)

$35 co-payment

Routine Hearing Exams (Non-Medicare covered)

$0 co-payment for one hearing exam every 3 years

Hearing aids

Up to $500 for one single ear every 3 years. $0 copayment for Fitting/Evaluation for Hearing Aid every 3 years.

Diagnostic Vision Exams (Medicare covered only)

$25 co-payment

Routine Vision Exam (one every year)

$0 co-payment for one routine eye exam for eyewear

Routine Eyewear

Up to $150 annual maximum per calendar year including contact lenses or eyeglasses (lenses and frames).

Vision Eyewear

$0 copayment for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.

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Elderplan Extra Help (HMO) BENEFIT

YOU PAY

Preventive Services

$0 co-payment

Diabetic Supplies

$0 co-insurance

Home Health Services

$0 co-payment.

Authorization is required.

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Elderplan Extra Help (HMO) Recap of a few plan highlights: 4 Low-cost sharing on prescription drugs (depending on LIS level) 4 $0 copayment for your in-network PCP, including telehealth 4 There are no referrals necessary for in network specialists 4 You can choose from quality board-certified private practice providers 4 You will receive up to $240 a year for over the counter *(OTC) health related, select healthy grocery items and meals**

4 Fitness Benefits (Gym) at participating Silver&Fit® fitness centers and YMCAs. Plus over 8,000 digital exercise videos available online

4 Supplemental Preventive and Comprehensive Dental coverage 4 Elderplan is a not-for-profit organization, reinvesting our earnings to bring you improved benefits and services *Unused OTC card balance cannot be carried over from month to month. **Grocery items and meals for eligible members (with certain chronic conditions)

51

Ready to Join the Elderplan Family?

We just need to complete your enrollment application and you’re all set!

4 Choose your PCP 4 Remember you must use in-network providers for routine services with the exception of emergency, urgently needed services and out-of-network dialysis 4 You must also use Elderplan’s pharmacy network which includes standard retail, mail-order, long-term care and home infusion pharmacies.

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Elderplan Cares You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call: 4 The Centers for Medicare and Medicaid Services (CMS) at 1-800-Medicare (1-800-633-4227). TTY/TTD users should call 1-877-486-2048, 24 hours a day/7 days a week; 4 The Social Security Administration at 1-800-772-1213 between 7 am and 7 pm, Monday through Friday. TTY/TTD users should call 1-800-325-0778; or the 4 The New York State Medicaid Helpline 1-800-541-2831 (TTY 711) from 8 am to 5 pm Monday through Friday.

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