Generations Advantage

DURING THE PHE: Make sure to bring your Martin’s Point Generations Advantage identification card as your Generations Advantage plan is the primary payer for COVID-19 vaccines. You won’t pay a copay for a COVID-19 vaccine and, if your plan has a prescription deductible, your deductible will not apply to the cost of the COVID-19 vaccine.

For information on the distribution and availability of the COVID-19 vaccine, please visit https://www.vaccines.gov/search/

AFTER THE PHE ENDS: (Effective starting May 12, 2023): No changes. Same coverage as DURING THE PHE (see above).

DURING THE PHE: KF94, KN95, and N95 masks reimbursable through Wellness Wallet. On January 14, 2022, the Centers for Disease Control and Prevention (CDC) recommended these masks to further limit the spread of COVID-19. Your Wellness Wallet reimburses for KF94 and KN95 masks purchased on 1/1/22 or later, and N95 masks purchased on 1/14/22 or later. Cloth masks and surgical masks are also reimbursable.

For details, see the Wellness Wallet webpage.

AFTER THE PHE ENDS: (Effective starting May 12, 2023): No changes. Same coverage as DURING THE PHE (see above). 

TESTS DONE AT MEDICAL FACILITIES OR DOCTOR'S OFFICE

DURING THE PHE: Tests done at a test facility or doctor’s office are covered if they are medically necessary—this includes if you have COVID-19 symptoms or are symptom-free but have been exposed to someone with COVID-19.

 **Travel- or work-related tests are not covered.**

Find a test site at your state’s health department website:

• Maine: https://www.maine.gov/covid19/testing

• New Hampshire: https://www.covid19.nh.gov/resources/testing-guidance

AFTER THE PHE ENDS: (Effective starting May 12, 2023): You will continue to pay no cost share for laboratory conducted COVID-19 tests if they are medically necessary and ordered by your provider. 

DURING THE PHE: If you are diagnosed with the Coronavirus (COVID-19), copays/coinsurance will be waived for the following services if related to COVID-19:

• Emergency room visits
• Urgent care visits
• Office visits
• Telehealth services.

AFTER THE PHE ENDS: (Effective starting May 12, 2023): If you are diagnosed with the Coronavirus (COVID-19), copays/coinsurance will only be waived for the following COVID-19 treatments:

• COVID-19 Oral Antivirals
• COVID-19 Monoclonal Antibodies

For all other services, cost sharing will apply based on your plan benefits.

DURING THE PHE:  If you are admitted to a hospital, the standard inpatient copay will still apply.

AFTER THE PHE ENDS: (Effective starting May 12, 2023):  No changes. Same coverage as DURING THE PHE (see above). 

DURING THE PHE: Following guidance from The Centers for Medicare and Medicaid Services (CMS), during the declared Public Health Emergency, all medical services normally covered by your plan at in-network levels will be covered with in-network member cost shares, even if you receive them from out-of-network providers. This applies to all Generations Advantage plans.

AFTER THE PHE ENDS: (Effective starting May 12, 2023):  Network requirements will return for all services except those designated by CMS, and cost-sharing will be applied based on the member’s plan benefits

Generations Advantage Prime (HMO-POS) and Select (PPO) plans–covered out-of-network services are subject to out-of-network cost shares. (See Exception*).

Generations Advantage Value Plus (HMO), Alliance (HMO) and Focus DC (HMO SNP) plans— there is no coverage for services performed by out-of-network providers (See Exception*).

*EXCEPTION for ALL Generations Advantage plans: Urgent and emergency care are always covered with in-network cost shares, even if received out of network. In addition, if there are no in-network providers who can deliver a particular service in your area, the service can be evaluated by the health plan for in-network cost sharing.

DURING THE PHE: Generations Advantage covers all telehealth services covered by Original Medicare. Due to the COVID-19 outbreak, Medicare has relaxed their requirements for telehealth services to allow members to get needed care. Copays for any telehealth services related to COVID-19 will be waived.

For all other visits, the in-network primary care copays will apply for telehealth services with a primary care provider, and in-network specialist copays will apply for telehealth services with a specialist. These copay amounts will be the same as if you received care through an in-office visit.

AFTER THE PHE ENDS: (Effective starting May 12, 2023):  Generations Advantage will continue to cover all telehealth services covered by Original Medicare. Cost-sharing for any telehealth service will apply based on your benefit plan. These copay amounts will be the same as if you received care through an in-office visit.