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

What is Kalos Health Gold Plus HMO-SNP?
Kalos Health Gold Plus is a Health Maintenance Organization (HMO) Special Needs Plan (SNP) with a Medicare Contract and a coordination of benefits agreement with the New York State Department of Health.  It is a specially designed Medicare Advantage Plan for those who have Medicare and full New York State Medicaid benefits.  For more information contact us at 1-800-399-1954 (TTY: 711).
What is Medicare Advantage?
Medicare Advantage Plans are available from private insurance companies approved by and contracted with the Centers for Medicare and Medicaid (CMS) to offer you, as a Medicare beneficiary, another way to receive your Medicare benefits.

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.

Do I need Medicare Part A and Medicare Part B to enroll in a Medicare Advantage Plan?
Yes. Before you enroll in a Medicare Advantage Plan sign up for Part A and Part B. If you have worked and paid into Medicare through payroll taxes for 40 quarters (10 years) you will not pay a premium for Part A. Part B premiums are usually deducted from your Social Security income. Your annual income determines your Part B premium.
What Does Kalos Health Gold Plus Cover?
Like all Medicare health plans, we cover everything that traditional Medicare covers and more.

  • 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.
Who Can Join?
To join Kalos Health Gold Plus HMO-SNP, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and in New York State Medicaid, and live in our service area. Our service areas include the following counties in New York: Cattaraugus, Erie, Niagara and Orleans Counties.
What do we cover?
Like all Medicare health plans, we cover everything that traditional Medicare covers — Part A (hospital services) and Part B (medical services), plus more. Our plan members also get more than what is covered by traditional Medicare. Some of the extra benefits are outlined in our Summary of Benefits.

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.

Can I use any pharmacy to fill my covered prescriptions?
To receive the lowest out-of-pocket costs on your covered Part D drugs, you must use a pharmacy in our network. If you use a pharmacy that is not in our network, please notify us.  We will work with our vendor to include the pharmacy in network; otherwise, you may pay more for your medications. Our network includes preferred and standard pharmacies. You may go to either type of network pharmacy to receive your covered prescriptions.
Can I enroll in a Medicare Advantage Plan if I have preexisting medical conditions?
The only preexisting medical condition that will disqualify you from enrolling in Kalos Health Gold Plus is End-Stage-Renal Disease (ESRD). Once enrolled you will not have any exclusions or waiting periods to use your plan. You will be entitled to all the benefits Medicare has to offer.
Can I enroll or disenroll at any time?

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.

What does “Extra Help” mean?
“Extra Help” is a subsidy that Medicare offers to certain beneficiaries to help pay for prescription drug costs.  People with limited income and resources may qualify for “Extra Help.” 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:

  • 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.”

How does Kalos Health Gold Plus work?

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.

What is the monthly premium for Kalos Health Gold Plus?
There is no premium for Kalos Health Gold Plus in 2018. You must continue to pay your Medicare Part B premium.
Does Kalos Health Gold Plus issue member identification cards?
Yes. Members should carry their Kalos Health Gold Plus member ID card and use it when they get medical care and prescription drugs. While enrolled in Kalos Health Gold Plus, members must not use their red, white and blue Medicare card for services. They should put the Medicare card away for safekeeping should they ever leave the plan and choose to go back to traditional Medicare coverage.
Can members see any provider they wish?

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.).

Can members use any pharmacy they wish?
No. Kalos Health Gold Plus is an HMO and has a pharmacy network that includes many of the large national chain pharmacies like Walgreens, Rite Aid and CVS.  In most cases, prescriptions are covered only if they are filled at the plan’s network pharmacies.
What if a member needs urgent care?

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.

What if a member has a life-threatening emergency?

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

What happens if a member gets sick outside of the services area?

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.

What happens if a member is traveling outside of the plan’s service area and he/she needs to fill a prescription?

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

How do I enroll?
Enrolling in Kalos Health Gold Plus is easy.  If you would like to enroll in the plan, you can:

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.