Triple-S ELA Care Plus Health Insurance
Who is eligible for this plan?
Care Plus ELA is the plan for government retirees subscribed to Parts A and B of Medicare. In addition, optional dependents of active government employees will be eligible for the supplemental coverage as long as they are not subscribed to Medicare on grounds of disability or End Stage Renal Disease (ESRD).
What is Care Plus ELA?
Your supplemental coverage, Care Plus ELA, provides Benefits for persons with both parts of the Medicare Program (Parts A and B) and is subject to the guidelines established by the Medicare Program. The plan insures the eligible person with the acceptable expense for deductibles and coinsurances, in accordance to the accepted charges by Medicare, for medical-surgical services and other health services received under Medicare. The Medicare program pays 80% of the reasonable charges after deducting the annual deductible. Your Care Plus ELA pays the remaining 20% of the reasonable charges accepted by Medicare.
The changes made as a result of Federal Legislation in the amounts of deductibles or coinsurance established by Medicare, will be covered by Triple-S Salud in accordance with the coverage dispositions. Care Plus ELA will covered the amounts approved by Medicare in Puerto Rico based on the usual, customary and reasonable charges.
The following table describes some of the benefits, deductibles and coinsurances covered by Medicare and Your Care Plus ELA plan.
|BENEFITS||MEDICARE||CARE PLUS ELA||YOU|
|Deductible for illness period||$0||$1,364||$0|
|First 60 days||100%||$0||$0|
|Coinsurance days 61 al 90||All, except $341 daily||$341 daily||$0|
|Coinsurance days 91 al 150||All, except $682 daily||$682 daily||$0|
|Lifetime reserve days (365 days per lifetime)||$0||100% of the eligible expenses of Medicare||$0*|
|More than 365 days||$0||$0||All expenses|
|SKILLED NURSING FACILITY|
|First 20 days||100%||$0||$0|
|Coinsurance days 21 al 100||All, except $170.50 daily||$170.50 daily||$0|
|Day 101 and subsequent days||$0||$0||All expenses|
MEDICAL SERVICES IN AND OUT OF THE HOSPITAL
Physician services, supplies and medical services for hospitalized and ambulatory patients, physical and speech therapy, diagnostic tests, durable medical equipment.
|Charges in excess of Part B (over the amounts approved by Medicare)||$0||$0||All expenses|
OUT OF AREA TRIPS – NOT COVERED BY MEDICARE
Medically necessary services for emergency care beginning during the first 60 days of every trip outside the United States of America.
|First $250 every calendar year||$0||$0||$250|
|Remaining charges||$0||80% up to a Lifetime maximum benefit of $50,000||20% and amounts over the Lifetime maximum of $50,000|
* When your Part A Medicare hospital benefit has been exhausted, Triple-S Salud will pay any amount Medicare would have paid up to 365 additional days, as provided in the policy’s basic coverage. During this period the hospital cannot charge you for the balance based in any difference between the billed charges and the amount Medicare would have paid.
Care Plus ELA Summary of Coverage
In the Care Plus ELA Summary, you will find detailed information about your costs and Medicare health coverage as well as how to obtain the medical services you need in Puerto Rico and the United States. Learn all the details.
ELA Individual Pharmacy Plan Brochure and Policy
The brochure for the ELA Individual Pharmacy plan provides a summary of benefits under the plan, some of the copays and/or coinsurances applicable for the purchase of prescribed drugs.
You will find detailed information about your standalone Rx plan, copays and/or coinsurances applicable for the purchase of medically necessary drugs and included in your Prescription Drug list.
This Standalone Rx plan is not a substitute for Medicare's Part D, nor does it substitute medication benefits covered under Medicare. It does not pay for Medicare's deductibles or coinsurances and it is not a substitute for any supplemental Medicare coverage.
This document presents the established premiums for the active and retired government employee, approved by ASES.
ELA Frequently Asked Questions