Organization/Plan Name Low Income Subsidy LIS Premium Summary Chart
User Manual: Low-Income-Subsidy-LIS-Premium-Summary-Chart
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GuildNet Gold HMO SNP Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan. This table shows you what your monthly plan premium will be if you get extra help. Your level of extra help 100% 75% 50% 25% Monthly Premium for GuildNet Gold* $0 $0 $0 $0 *This does not include any Medicare Part B premium you may have to pay. GuildNet Gold’s premium includes coverage for both medical services and prescription drug coverage. If you aren’t getting extra help, you can see if you qualify by calling: • 1-800-Medicare of TTY users call 1-877-486-2048 (24 hours a day/7 days a week), • Your State Medicaid Office, or • The Social Security Administration at 1-800-772-1213. TTY users should call 1-800325-0778 between 7 a.m. and 7 p.m., Monday through Friday. If you have any questions, please call Member Services at 1-800-815-0000, TTY 711, Monday through Sunday, 8am to 8pm EST, or at www.guildnetny.org. GuildNet Gold is an HMO SNP plan with a Medicare and New York State Medicaid contract. Enrollment in GuildNet Gold depends upon contract renewal. Premium and or co-payments may change on January 1 of each year. You must continue to pay your Medicare Part B premium. If you have full Medicaid coverage, the State Medicaid plan pays the Medicare Part B premium for you. H6864_GN575_LIS Premium Summary 2018 Accepted 250 West 57th Street, New York, NY 10107 ● 1-800-815-0000 ● F: 646-619-6093 ● www.guildnetny.org This information is available for free in other languages. Please contact our member services at 1-800-815-0000, 8am to 8pm, Monday through Sunday. TTY users call 711. Esta información está disponible sin cargo en otros idiomas. Por favor llame a los números de servicio al miembro al 1-800-815-0000 (solo los usuarios de TTY 711 para obtener información adicional. El servicio al miembro está disponible lunes a domingo, de 8am a 8pm.
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