FAQs – Frequently asked questions about Kalos Health Gold Plus HMO-SNP

When you have a Medicare Advantage Plan you will receive your Part A (hospital insurance) and Part B (medical insurance) from the Advantage Plan. Medicare Advantage Plans must cover all services covered under traditional Medicare.

• In addition to traditional Medicare benefits, our plan members also get hearing aids, preventive care, wellness programs and more.
• Kalos Health Gold Plus plan covers Part D drugs. Part B drugs such as chemotherapy and some drugs administered by your provider are also covered.

Medicare Part D drugs and Part B drugs (such as chemotherapy and some drugs administered by your provider). To see if your drugs are covered, you can view the plan’s Formulary (list of covered Part D prescription drugs) and any restrictions on our website at www.kaloshealth.org. or you can call us for a copy of the Formulary.

Beneficiaries with Medicare and Medicaid benefits (dual-eligibles) and those with Medicare who are receiving “Extra Help” from Medicare can join the plan at any time and disenroll at any time.

• 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 at 1-800-772-1213, between 7 a.m. to 7 p.m., Monday through Friday.  TTY users should call 1-800-325-0778; or
• Your New York State Medicaid Office at 1-800-541-2831.

Some people automatically qualify for “Extra Help” and don’t need to apply. Medicare mails a letter to people who automatically qualify for “Extra Help.”

The plan has contracts with doctors, hospitals, ancillary providers and pharmacies to provide members with all of their medical care and prescription drug needs. Members must choose a primary care physician (PCP) who is responsible for the coordination of their care. To have Kalos Health Gold Plus cover members’ care, they must get it from network providers except in limited circumstances, such as when emergency care or urgently needed care is necessary and the provider network is not available.

Kalos Health Gold Plus is an HMO with a provider network. You generally must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered.

There are exceptions like emergency or urgent care, which are covered by the plan when you use out-of-network providers; if you need covered medical care and there is no appropriate provider in our network (you must have an authorization from the plan before you seek care from an out-of-network provider; and kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.).

During business hours, he/she should contact his/her primary care provider (PCP) for help. If the PCP is unavailable, he/she should go to a network urgent care center. If there is no network urgent care center available, he/she should go to the closest Urgent Care Center or hospital emergency room. Members can also call the After Hours Nurse Advice Line for help from a Registered Nurse when their PCP’s office is closed.

He/she should call 911 and/or go to the nearest hospital with an emergency room.

Go to the nearest urgent care center or hospital with an emergency room. Members should contact their primary care provider or RN Care Manager as soon as possible (usually within 48 hours), as well as tell Member Services.

Members can go to any network pharmacy, which includes the big national chain pharmacies, such as Walgreens, CVS, Rite Aid, etc.

Contact Member Services by phone at 1-800-399-1954 (TTY: 711) or email at [email protected].

You can also access our website at www.kaloshealth.org and download the enrollment application form.  Complete the form and fax or email them to us.  Our fax number is 716-731-2013.