Elderplan 2026 Medicaid Benefit Grid

This cheat sheet outlines the benefits and cost-sharing for two Elderplan Medicaid plans (Plan 002 and Plan 007) in 2026, detailing coverage for various medical services and supplies.

Core Principles

Plan 002 offers coordination of benefits with DOH (Medicaid) for dual eligibles, with cost-sharing varying by Medicaid eligibility.
Plan 007 (Elderplan Plus Long Term Care) has no cost-sharing for members and may include additional Medicaid benefits.
Both plans provide coverage for a wide range of services, including inpatient and outpatient care, specialist visits, and prescription drugs.
Authorization is frequently required for specific services, especially for Plan 002.
Medicaid Coordination of Benefits is a key factor in determining coverage and cost-sharing for many services.
Supplemental benefits, such as OTC allowances and fitness programs, are offered by both plans.
Specific limitations and conditions apply to certain benefits, such as hearing aids and durable medical equipment.

Action Steps

Review the specific plan details (Plan 002 or Plan 007) relevant to your needs.
Check the 'Authorization Required' column for any service before seeking care.
Understand your cost-sharing responsibilities, especially for Plan 002, based on your Medicaid eligibility.
Verify if a service is covered by Medicare or Medicaid, as this impacts the benefit grid.
Consult the Elderplan Evidence of Coverage (EOC) for a complete list of covered conditions and services.
Contact Elderplan directly for any clarification on benefits or coverage details.

Key Terms

Coordination of Benefits (COB): A system that determines which insurance plan pays first when a person has more than one insurance policy.
Cost-Sharing: The portion of healthcare costs that a member is responsible for paying, such as deductibles, copayments, and coinsurance.
Deductible: The amount a member must pay for covered healthcare services before their insurance plan starts to pay.
Copayment: A fixed amount a member pays for a covered healthcare service after they've paid their deductible.
Coinsurance: A member's share of the costs of a covered healthcare service, calculated as a percentage (e.g., 20%) of the allowed amount for the service.
Authorization Required: Indicates that prior approval from the insurance plan is necessary before receiving a specific service or treatment.
In-Network: Providers or services within the insurance plan's network of contracted healthcare facilities and professionals.
Out-of-Network: Providers or services that are not part of the insurance plan's network.
LIS/Extra Help: Low-Income Subsidy program that helps Medicare beneficiaries with limited income and resources pay for prescription drugs.
SSBCI: Special Supplemental Benefits for the Chronically Ill, which can include benefits like OTC allowances and meal services.