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About Medicare Advantage Plans
About Medicare Part D plans
About Medicare Supplement (Medigap) Plans
About Medicare Advantage Plans What are Medicare Advantage plans? Medicare Advantage plans are an alternative to Original Medicare that provide an equivalent or better level of coverage. We have a contract with the federal Medicare program to coordinate your Medicare benefits and provide for your medical coverage. It's pretty simple; Medicare pays us and we cover you. Do I lose my Medicare benefits when I join HAP Senior Plus or Alliance Medicare PPO? No. You are still in the Medicare program. In fact, you must have and keep, both Medicare Part A and Part B in order to enroll in our Medicare Advantage plan. We have a contract with the federal government to provide our plans to Medicare beneficiaries. As a member of HAP Senior Plus or Alliance Medicare PPO, you receive all of your Medicare-covered services through your plan. Your benefits include all the benefits you are entitled to under Medicare, including the option for prescription drug coverage. Plus, you get a full range of additional health care benefits, including preventive care services. See the Summary of Benefits for more benefit information about the plan in which you're interested. Can I go to any doctor or hospital I want? As a member of Alliance Medicare PPO, you can use any Medicare-participating provider. When you use a provider within our contracted network, you receive the maximum benefit. Services received for routine care from Medicare-participating providers outside of our network will generally cost more (i.e., have higher copay and co-insurance costs) except in emergency or urgent care situations. When you enroll in HAP Senior Plus, you chose a Personal Care Physician. As your partner in health care, your PCP coordinates all your care. You must use providers, such as specialists and hospitals, in your PCP's network, except in an emergency. Any specialist services you may need require a referral from your PCP, with some exceptions. If you choose to go to a doctor outside the network, you must pay for the services yourself. Neither HAP nor Original Medicare will pay for out-of-network services. In every plan, you must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party. Will I have trouble getting a referral to a specialist? What if my Personal Care Physician won't refer me to a specialist? Our primary focus is to keep you well. That means you will be able to see a specialist whenever there's a medical reason to do so. Your PCP will refer you to the appropriate specialist, and will coordinate services for all of your health care needs. If you prefer not using referrals, you may want to consider our PPO plan. Can I use my specialist as my Personal Care Physician? Personal Care Physicians, known as Internal Medicine or Family Practice doctors have had special study and training in the prevention and treatment of conditions that affect adults. Internists are sometimes referred to as the "doctor's doctor," because they are often called upon to act as consultants to other physicians to help solve puzzling diagnostic problems. Your Personal Care Physician, who is the trained professional, would refer you to the appropriate specialist. They also bring to patients an understanding of wellness, disease prevention and the promotion of health. HAP stresses preventive care and encourages you to establish a relationship with your PCP. Keep in mind, specialists receive training that tends to make them focus on one part of your body, and sometimes they do not consider factors outside their specialty. A Personal Care Physician also looks at all care you are receiving from all specialists. A PCP, for example, can ensure that prescriptions provided by different specialists will not conflict with each other. In fact, recent studies have shown that almost 10 percent of all seniors are taking combinations of medications that could be dangerous -- in other words, they are over-medicated. I see two doctors that I use and both are in your HAP Senior Plus plan. The Specialist is in one network and the Internal Medicine doctor is in another. Am I able to use them both? Generally the answer is no. In order to see a specialist at Henry Ford Hospital, for instance, you would need to select a Personal Care Physician affiliated with that network. However, the Henry Ford Health System network is extensive. If you elect to use Beaumont Hospital, for example, you would use Beaumont physicians; if Beaumont does not offer a particular service you need, your Beaumont Personal Care Physician would refer you elsewhere for that particular service. The reason for this is that the Personal Care Physician affiliated with a particular hospital has helped us in selecting the specialist they want to work with to help care for you, as well as the fact that your medical records do not need to be transferred from network to network. If your current mix of physicians is not all in one network, you could (a) consider changing to whichever network you prefer or (b) consider our Alliance Medicare PPO product. What do I do if I would like to switch my doctor? You can either call our Client Services department to request help with selecting or changing your PCP or you can go online and make the change. You will get a new ID card with your new doctor's name on it. Do you cover long-term care or nursing home care? Neither Medicare Advantage plans nor Medicare Supplemental insurance cover long-term care needs. This benefit would be covered under a long-term care insurance policy that you purchase separately. What happens if I go to the emergency room for something I thought required immediate medical attention, and find out it was not an emergency? We encourage you to seek medical care when you feel it's necessary. If you believe you're having an emergency, go to the emergency room for medical treatment. Your plan will pay the claim based on why you went to the emergency room, not on the diagnosis or final outcome of your treatment. What if I have a pre-existing condition? Will I be able to join now or will I have to wait for medical treatments for that condition? All of your plan benefits start the first day your Medicare Advantage plan coverage takes effect. There are no exclusions or waiting periods for pre-existing conditions. The only medical condition that would prevent you from joining is End Stage Renal Disease, unless you already are a member of a HAP plan. Once you're a Medicare Advantage member, your rates cannot be raised for any medical condition and you cannot be canceled for any medical condition. Will I have to submit claims for the services I receive? As an HMO or PPO member, you don't have to submit claim forms for services provided by network providers. For example, if you see your doctor for an annual checkup, your doctor will bill us and you pay your copay. If you have an emergency or urgent care situation while out of our service area, you may be required to pay for services when you receive them, and then submit a claim for reimbursement by mailing a copy of the claim to us. If you use routine services out-of-network under your PPO coverage, you may also need to submit a claim for reimbursement. Can I enroll in both a Medicare Advantage plan and a stand-alone prescription drug plan? No. Medicare does not allow enrollment in multiple Medicare-approved plans. Medicare Advantage plans with prescription drugs include both medical and Part D prescription drug coverage, so there is no need to enroll in an additional drug plan. Generally, unless you cancel your Medicare Part B coverage or permanently move out of the plan's service area or leave the area for an extended absence of more than six months, you cannot be cancelled involuntarily. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. Medicare Advantage plans and Medicare prescription drug plans have contracts with Medicare, and agree to stay in the program for a full year at a time. Each year, that contract is renewed. If your plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. Even if your plan leaves the program, you will not lose Medicare coverage. You would still have Original Medicare or you could enroll in a different Medicare-approved plan. How can I get more information about Medicare benefits or HAP's Medicare Solutions? If you are not a HAP member, please call us at (800) 868-3153 toll-free or TDD (800) 956-4325 toll-free, Monday – Friday 8:30 a.m. To 5:00 p.m. Ask for our free booklet, "Making Sense of Medicare," which provides an overview of the Medicare program and the choices you have as a Medicare beneficiary. Your Customer Service Representative can also provide assistance and answer questions about benefits and coverage. If you are a HAP member, call your Customer Service Representative: Alliance Medicare Rx Our hours are 8 a.m. to 8 p.m., Monday through Friday, You can also contact Medicare at www.medicare.gov on the Web. Or call Medicare toll-free at (800) MEDICARE ((800) 633-4227), 24 hours a day, seven days a week. TTY users should call (877) 486-2048. What happens if I just keep my Original Medicare plan? There are gaps in the coverage Original Medicare provides. Medicare pays a share of the Medicare-approved amount, and you pay your share — co-insurance, copays and up-front deductibles. In some cases, you may be charged more than the Medicare-approved amount. If you experience a serious illness or have multiple conditions, these out-of-pocket costs can become significant. What is a Medicare Supplement or Medigap policy? A Medicare Supplement insurance policy (also known as Medigap) is sold by private insurance companies to fill "gaps" in Original Medicare plan coverage. It's a plan that helps pay your share of hospital and medical costs — your co-insurance, copays and deductibles. Medigap policies only work with the Original Medicare Plan and do not include any benefits not covered by Medicare (such as dental, eyeglasses or hearing aids). What is the difference between a deductible and co-insurance? A deductible is the amount you must pay for health care services, before Medicare begins to pay. The deductible amount can change every year. Co-insurance is a percentage (generally 20%) of the Medicare-approved amount that you must pay after you pay your deductible. A copay is a set amount you pay for medical services. For example, for a doctor's office visit, your copay may be $15 or $20. What is an urgent medical condition? Sprained ankles, most burns, minor wounds requiring stitches, back pain, chronic headaches, urinary tract infections and severe cold or flu are typical examples of urgent conditions. An urgent condition is not life threatening but may require prompt attention. Urgent care access standards require care on the same day or next day depending on the severity of the condition. Contact your Personal Care Physician's (PCP's) office for urgent care instructions. Often urgent care conditions may be treated in your physician's office. When you call with an urgent need, request a same or next day appointment. Your PCP has appointments available for patients with urgent conditions. In fact, it is better to visit your PCP in an urgent situation rather than going to an emergency room because your PCP is aware of your medical history and any care that you are currently receiving. If your PCP is not available and other arrangements cannot be made through his or her office, you may go to any HAP-affiliated urgent care facility. If you are outside of our service area, you may seek urgent care at any urgent care facility. What is an emergency medical condition? A "medical emergency" occurs when you reasonably believe that your health is in serious danger and every second counts. A medical emergency includes severe pain, a bad injury, a serious illness, or a medical condition that is quickly getting much worse. Emergency care is available 24 hours a day, seven days a week at emergency facilities. If you experience a medical emergency, go to the nearest emergency facility or call 911 for assistance. After a visit to an emergency room, you should follow up with your PCP. This ensures that any additional care will be coordinated through your PCP, that your medical records and history are updated, and that your treatment reflects any existing conditions or medications. What is the difference between urgent and emergency care? Emergency care is more serious than urgently, needed care. Emergencies are most commonly treated at a hospital emergency room. Urgent needs can often be treated by your PCP. If an urgent need arises when you are traveling, it can usually be treated at an urgent care center. In both cases, the need is unexpected, could not have been scheduled, and should not wait for treatment at some future date. Why is it important to know the difference between urgent and emergency conditions? Knowing the difference between urgent and emergency medical conditions will help you determine how to obtain the most appropriate care, can save you costly copays and can ensure that you are treated as quickly as your condition requires. What role does my PCP play in urgent and emergency care? Your PCP has a very important role in every aspect of your health care including urgent and emergency care. BEFORE the need arises contact your PCP's office for instructions regarding urgent and emergency situations. Remember, your PCP is your partner in maintaining your health. Because your PCP coordinates all of your medical care, it is important that you contact his or her office after receiving emergency treatment. Follow-up care must be arranged through your PCP. What should I do when I'm traveling? We offer worldwide health care coverage for medical emergencies, accidental injuries and urgent care. Remember that in an emergency situation you can always call 911 in the United States or go to the nearest emergency room. Generally the site where you seek care will ask for your health insurance card (your HAP or Alliance ID card) and call the number on the back for billing or coverage questions. If the physician or hospital does not recognize your ID card and requires immediate payment for services, you are responsible for paying the hospital or physician. We will fully reimburse you for the covered services less any copays you are required to pay. Just send your receipts to:
If you are admitted to a hospital not affiliated with us, you or your designee should notify us within 48 hours at the number listed on the back of your ID card. You can review a complete list of approved Urgent Care Centers within our 9 county service by going to www.hap.org. Click on Doctors and Hospitals on the left, and then click on Urgent Care Centers.
About Medicare Prescription Drug Coverage (Part D) Do I have to get Part D prescription drug coverage? No. You can enroll in a HAP Senior Plus or Alliance Medicare PPO plan without prescription drug coverage. However, if you decide at a future date to elect Part D prescription drug coverage, you may pay a financial penalty assessed by Medicare. Can I get a prescription drug plan through HAP? Yes. You choose what's best for you. You can enroll in Alliance Medicare Rx plan, our stand-alone prescription drug plan. Or you can enroll in one of our Medicare Advantage plans, and can choose the Part D prescription drug benefit you prefer. "Creditable coverage" is the term the government uses to describe prescription-drug coverage that is at least as good as or better than what Medicare offers. If you are enrolled in Medicare and have a drug benefit through an employer's health plan, most likely that coverage will be considered "creditable coverage". If you lose those drug benefits, you will receive a certificate of creditable coverage that guarantees your right to buy a Medicare Part D plan within specified timeframes without paying a penalty for late enrollment. I don't use a lot of prescriptions. Should I still consider prescription drug coverage? By joining a plan now with basic prescription drug coverage, you can keep your premium costs low, and protect against unexpected expenses in the future. If you don't currently have creditable coverage, and you wait past the time you're initially eligible to enroll in a Part D plan, you may have to pay a penalty of 1% for every month you delayed enrollment. This penalty will continue through the rest of your years with Medicare coverage. I have Original Medicare, and I'm not sure I need prescription drug coverage. If you don't use a lot of prescription drugs now, you should still consider enrolling in a Part D plan. As people age, they often need prescription drugs to stay healthy. Joining now will secure the lowest possible plan premium. If you wait to join, you may have to pay a penalty. How will I know if the drug I take is covered? Each Medicare Part D plan provides its own list of covered drugs, called a formulary. There are three ways you can find out if a drug you're taking is covered.
What if my prescription drug is not on the HAP formulary? If you are taking a drug that is not on our formulary, you can talk with your doctor about whether a different drug might be an effective alternative for you. If an effective alternative is not available, you or your doctor can request an exception to allow coverage of the drug you use. How will I know if I've reached my limit on prescription coverage? Each month, you receive a statement of activity that shows your out-of-pocket cost to date and the remaining benefit amount. That ensures you won't have unpleasant surprises at the pharmacy. If you're concerned about the coverage gap (or "donut hole"), you may want to consider our Enhanced Plan that provides coverage for generic drugs through the coverage gap. What if I already have prescription drug coverage from a former employer? If you have prescription drug coverage now through your employer, you should review your plan and talk to your plan benefits administrator or insurer before making any changes. You will be notified by your employer about any changes to your current coverage so you can decide if a different plan is a better choice for you.
About Medicare Supplement (Medigap) Plans How do I know if I am I eligible for Alliance Medicare Supplement? When can I sign up for Alliance Medicare Supplement? Am I covered when I travel? Do I need a referral to see a specialist? Can I keep my Alliance Medicare Supplement policy if I move out of state? How can I get prescription drug coverage? Enroll | Contact Us | Glossary | Site Index | Privacy Statement ©2010 Health Alliance Plan of Michigan |
