Medicare

GENERAL INFORMATION

MEDICARE GAPS (items  not covered by medicare)

• Part A & B deductibles
• 20% of Part B medical services
• Services Medicare deems not medically necessary
• Permanent residence in an assisted living facility/nursing home
• Most health care received outside the United States
• Inpatient hospital & skilled nursing charges above Medicare’s limits
• Eyeglasses, dentures, hearing aids, routine dental care

MEDICARE SUPPLEMENT INSURANCE(also referred to as Medigap Insurance)
 

• Purchased from private insurance companies
• Supplements Original Medicare coverage
• Covers some or most of the costs that original Medicare does not pay
• Medicare pays before the Medicare Supplement policy pays
• Plans are standardized and can be purchased with varying premiums
• No provider network
• Guaranteed renewable as long as you pay your premium

MEDICARE ADVANTAGE HEALTH PLANS (MA)

• Most plans include extra benefits and out-of-pocket costs,
   which are generally lower than with Original Medicare
• You may need to use providers that participate with the plan

• Most Medicare advantage plans include a part D Plan  (MAPD)

If you have a illness like diabetes or a chronic heart condition, or if
you’re eligible for both Medicare and Medicaid, you may qualify
for a Medicare Advantage Special Needs Plan (Not available in all areas)

CHOICES IN MEDICARE ADVANTAGE (MA) PLANS

1. Health Maintenance Organization (HMO)
• Defined network of providers
• Primary Care Physician (PCP) coordinates all of your care
• A referral from your PCP to see a Specialist is usually required
• You must use network providers for all scheduled care
• Out-of-pocket costs may be significantly lower
2. Preferred Provider Organization (PPO)
• Defined network of providers
• Flexibility to use providers who are not part of the network
• No referral needed to see any doctor
• Out-of-pocket costs increase when out-of-network providers are used
• Greatest savings when network providers are used

PRIVATE-FEE-FOR-SERVICE (PFFS)
PFFS is a type of Medicare Advantage plan offered by a private insurance company. You may receive services from any provider allowed to bill Medicare who agrees to accept the PFFS plan’s payment terms and conditions. There are three types of PFFS plan networks.
• Full network PFFS plans: The plan will have network providers (that is, providers who have signed contracts with the plan) for all services covered under Original Medicare.
• Partial network PFFS plans: The plan will have network providers (that is, providers who have signed contracts with the plan). The partial network PFFS plan should indicate the category or categories of services for which network providers are available.
• Non-network PFFS plans: Your provider is not required to agree to accept the plan’s terms and conditions of payment, and thus may choose not to treat you, with the exception of emergencies.
• A PFFS plan pays instead of Medicare.
• You pay the amount the PFFS plan does not pay; these are called copayment or coinsurance.
• It is not the same as the Original Medicare plan that is offered by the Federal Government.
• It is not a Medicare supplement (Medigap), Medicare Select, or a stand-alone Prescription Drug Plan.

SPECIAL NEEDS PLANS (SNP)
SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.

LATE ENROLLMENT PENALTY

Medicare beneficiaries may incur a Late Enrollment Penalty (LEP) if there is a continuous period of 63 days or more. At any time after the end of the individual Part D initial enrollment period, during which a beneficiary was eligible to enroll, but was not enrolled in a Medicare Part D plan and was not covered under any creditable prescription drug coverage.

UNDERSTANDING YOUR FORMULARY

Medication Therapy Management (MTM program)
Maximize your medication therapy results and minimize your out-of-pocket drug costs with the help of a pharmacist who will become your personal resource and advocate at no additional cost to you.

Step Therapy Program
Step Therapy focuses on encouraging the use of cost-effective drugs as first line treatment when therapeutically appropriate. Certain drugs are grouped in a logical series of steps that a doctor can follow with treatment.

Transition of Care
In many cases, The Plan will cover up to a one-month transition supply for Part D drugs not on our formulary, no longer part of our formulary or if access to the drug is limited.

Drug Exceptions and Prior Authorizations 
If a drug is not covered by The Plan formulary or has coverage restrictions you can submit an exception request to have your drug covered or have restrictions waived. If a drug is not removed from The Plan formulary, or if prior authorization, quantity limits and/or step therapy restriction are added, The Plan will notify you of the change in advance

Formulary Exception
You can ask The Plan to make exception to the coverage rules

Cost Tiers
Each drug is categorized by Tier, which determines how much you will pay for that drug.