Frequently Asked Medicare Questions

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Medicare Questions and Answers

General

You automatically qualify for Medicare if:

  • You already receive benefits from Social Security or the Railroad Retirement Board (RRB).
  • You are under 65 and have a disability.
  • You have ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig's disease).
  • You live in Puerto Rico and get benefits from Social Security or the RRB.

If none of the above applies to you, you can sign up manually if:

  • You aren’t receiving Social Security or RRB benefits.
  • You qualify for Medicare because you have End-Stage Renal Disease.
  • You live in Puerto Rico and want to sign up for Part B. (You must already have Part A to apply for Part B.)

What is Medicare Part A?
Medicare Part A (hospital insurance) helps pay for medical care that involves an inpatient hospital stay or a stay in a skilled nursing facility as a follow-up to a hospital stay. It also covers hospice care, some skilled in-home health care and some blood transfusions.

What is Medicare Part B?
Medicare Part B (medical insurance) helps pay for doctor office visits, outpatient hospital and clinic care, laboratory tests, some diagnostic screenings and skilled nursing care. The premium you pay for Part B is deducted from your Social Security benefits.

What is Medicare Advantage Part C?
Medicare Advantage Part C plans are Medicare-approved health plans administered by private health insurance companies like BlueCross BlueShield of Tennessee, and cover the same services as Original Medicare (Part A and Part B). Medicare Advantage plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D) and are called Medicare Advantage Prescription Drug Plans (MA-PD).

What is a Medicare Advantage Preferred Provider Organization (PPO) plan?
A PPO plan allows you to see any Medicare doctor you want. However, if you use a doctor who participates in the network, you usually get a better benefit and lower copayment or coinsurance than if you visit one who is out-of-network. These plans don't require you to have a referral to see a specialist.

What is a Medicare Advantage Health Maintenance Organization (HMO)?
Members of HMO plans must receive all of their health care from a network provider unless there is an emergency situation, urgent care or out-of-area dialysis is needed. HMOs require members to select a PCP to manage their health care. The PCP is the member’s personal doctor and provides all basic healthcare services. If a BlueChoice member chooses to go to a doctor outside of their HMO's network, they may be responsible for all or most of the cost. BlueChoice is the BlueCross BlueShield of Tennessee HMO plan.

What is a Medicare supplement plan (Medigap)?
Medicare pays for many healthcare services, but it doesn't cover everything. There are costs associated with hospital stays and doctor visits, and drug coverage is limited. Original Medicare pays a percentage of your medical claims, but a Medicare supplemental plan will pay most of the remaining balance. Our Medigap plan is called BlueElite.

Out-of-network/non-contracted providers are under no obligation to treat BlueAdvantage members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our member service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

 

Medicare Advantage

If I purchase a BlueAdvantage or BlueChoice plan, will I lose my Medicare coverage?
No. Medicare Advantage plans like BlueAdvantage and BlueChoice are part of the Medicare program and are administered by a private insurance company such as BlueCross under contract with Medicare.

Do BlueAdvantage and BlueChoice cover the same services as Original Medicare?
Yes. BlueAdvantage and BlueChoice cover the same services as Medicare, plus many that are not.

Why do I have to pay my Medicare Part B premium if Medicare Advantage plans pay my claims and not Medicare?
BlueCross BlueShield of Tennessee and other Medicare Advantage insurance companies have a contract with Medicare to provide your Part A and Part B coverage. As part of this contract, the plan receives payments from Medicare to cover the cost of your benefits. Your Part B premium, along with the premium you pay for the plan, make up the total premium needed to provide your Medicare Advantage benefits.

Will I still need to show my Medicare card when receiving health care services?
No. If you enroll in a Medicare Advantage plan, you will show your BlueAdvantage or BlueChoice ID card when receiving health care services. However, you should still keep your Medicare card in a safe place. Hospice care is still covered under Original Medicare and requires your Original Medicare Card.

Is there a waiting period before benefits will be paid on pre-existing medical conditions?
No. There is no pre-existing condition waiting period for BlueAdvantage or BlueChoice members.

Do I have to choose a Primary Care Physician (PCP)?
Yes. Having a PCP is an important part of managing your health. Our BlueAdvantage and BlueChoice members are asked to choose a PCP. We want to help you stay healthy, and a PCP can help you catch possible health issues – before they become more serious problems.

If you choose BlueAdvantage, you can see any Medicare doctor you want. But, you get the most from your benefits if you choose a doctor in your network. If you pick a BlueChoice plan, you should get care from a doctor in your network – unless it’s in an emergency or urgent care situation or you need out-of-area dialysis.

Do I need a referral to see a specialist?
BlueAdvantage PPO members are not required to have a referral to see a specialist. BlueChoice HMO members are not required to have a referral to see a specialist. If the member chooses to go to a doctor outside of their HMO's network, they may be responsible for all or most of the cost.

Once I select a Medicare Advantage plan, can I change plans later?
Unless you need to disenroll due to a major life change, you can only end your membership in any Medicare Advantage plan during the Annual Election Period (October 15 to December 7).

If any of the following situations apply to you, you may be eligible to end your membership during a Special Enrollment Period:

  • You have moved outside of the service area.
  • You have Medicaid.
  • You are eligible for Extra Help with paying for your Medicare prescriptions.
  • We substantially violate a material contract provision with you.
  • You are getting care in an institution, such as a nursing home or long-term care hospital.
  • You enroll in the Program of All-inclusive Care for the Elderly (PACE).

Once you’ve signed up, immediately following, you have a short period during the annual Medicare Advantage Disenrollment Period (January 1 to February 14) when you can cancel your plan, but your choices are more limited. You can cancel your Medicare Advantage Plan and switch to Original Medicare, you can switch to Original Medicare with a Medicare supplement or you can sign up for a standalone prescription drug plan. You cannot switch to a different Medicare Advantage plan during this time.

What happens to my coverage if BlueCross BlueShield of Tennessee leaves the Medicare program?
All health plans with Medicare contracts agree to stay with the Medicare program for a full year. Each year, plans can decide whether to continue for another year. The Centers for Medicare and Medicaid Services, which administers Medicare and other programs under the umbrella of the U.S. Department of Health & Human Services, can also decide not to renew a plan's contract. If a plan leaves the Medicare program, you will not lose Medicare coverage. You will receive notification 90 days in advance along with information about your other Medicare coverage options.

Will my BlueAdvantage or BlueChoice monthly premiums or benefits change next year?
BlueAdvantage and BlueChoice contracts are renewed annually with Medicare. The premiums, benefits, copays and coinsurance amounts can change annually. Members will receive an annual notice of change in the mail by September 30 for changes effective the following January 1.

What can I expect from my BlueAdvantage or BlueChoice coverage if I go to an out-of-network provider in an emergency situation?
In case of an emergency, you should always seek medical care from the closest available provider. You will receive in-network benefits for emergency care even if the provider is not in the network.

Will out-of-state doctors accept my BlueAdvantage or BlueChoice plan if I am traveling?*
With BlueAdvantage and BlueChoice, you are free to seek care from any health care provider that accepts Medicare payments. However, you must present your BlueAdvantage or BlueChoice ID card before you receive services.

BlueChoice members must use in-network providers in order to receive benefits except in emergency situations, urgent care or out-of-area dialysis.

What are my payment method options?
You have several.

  • Monthly Billing Statement
  • Bank Draft
  • Social Security Deduction

A person will not be disenrolled if their payment method is Bank Draft or Social Security.

For non-pay do I have a grace period?
Yes, you have a three calendar months grace period.

Example:
Plan XYZ has a three-month grace period for premium payment. Mr. Smith's premium was due on February 1. He didn't pay his premium.  On February 11, the plan sent a notice to Mr. Smith. He ignores this notice and any follow-up premium bills. The grace period is the month of April.

If Mr. Smith doesn't pay his plan premium before the end of April, he will be disenrolled as of May 1.

Can a plan disenroll a person if they didn't pay their monthly premium?
Yes, a plan can disenroll a member for non-payment of premiums after proper notice and an appropriate grace period.

What happens if a person is disenrolled from his or her plan for non-payment?
Someone who is disenrolled from a Medicare Advantage Plan will automatically be enrolled in Original Medicare. Generally, people with Medicare can only make changes to their coverage between October 15–December 7 each year or the Annual Election Period (AEP), unless they qualify for a Special Enrollment Period (SEP).

What are plans required to do before an individual is disenrolled from the plan?

  • Send a bill with the amount due and a due date.
  • Send a written notice of non-payment. The notice must explain that the person will be disenrolled from the plan if full payment hasn’t been made by the end of the grace period.

Can a person make partial payments?
Yes, but the full amount must be paid by the end of the grace period.

Can a person contact the plan to make a payment?

Yes, you can submit your payment by calling our member service line at 1-800-831-BLUE (2583) for PPO (TTY: 711) or 1-800-317-BLUE (2583) for HMO (TTY: 711) and one of our customer service representatives will gladly process and post your payment the same day.  The only way you can make a payment over the phone is by Bank Draft.

What is the service area for BlueAdvantage?
The state of Tennessee.

What is the service area for BlueChoice?
The BlueChoice service area includes Anderson, Bedford, Benton, Bledsoe, Blount, Bradley, Campbell, Cannon, Cheatham, Chester, Claiborne, Cocke, Coffee, Cumberland, Davidson, DeKalb, Fayette, Franklin, Gibson, Giles, Grainger, Greene, Grundy, Hamblen, Hamilton, Hancock, Hardeman, Hawkins, Henry, Hickman, Jackson, Jefferson, Knox, Lawrence, Lewis, Lincoln, Loudon, Madison, Marion, Marshall, Maury, Meigs, Monroe, Montgomery, Morgan, Overton, Perry, Polk, Rhea, Roane, Robertson, Rutherford, Sequatchie, Sevier, Shelby, Smith, Sullivan Sumner, Trousdale, Union, Warren, Wayne, White, Williamson and Wilson counties.

Out-of-network/non-contracted providers are under no obligation to treat BlueAdvantage members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our member service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Prescription Drug Coverage

What is a formulary?
A formulary is a list of drugs covered by the plan. We cover most drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other coverage rules are followed. Certain prescription drugs are subject to coverage limits.

How do I find out what drugs are on the formulary?
Call Member Service to find out if your drug is on the formulary or request a copy. Updated formularies are available at bcbstmedicare.com.

What if my drug is not on the formulary?
If your prescription isn't on the formulary, contact Member Service to be sure it isn't covered. If we don't cover your drug, you have three options:

  1. Ask your doctor to switch to a covered drug. For a list of covered drugs used for similar medical conditions, please contact Member Service.
  2. Ask for an exception (a type of coverage determination). See your Evidence of Coverage to learn more about how to request an exception.
  3. You can pay out-of-pocket for the drug and request reimbursement via an exception. This doesn't obligate the plan to reimburse you if the exception request is denied. If the exception is denied, you may appeal the plan's denial. See your Evidence of Coverage to learn how to request an appeal.

What are network pharmacies?
A network pharmacy is contracted with us to provide covered prescription drugs. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

If the drug is available as a generic, do I have to take the generic?
If a brand-name drug has a generic available, and only the generic drug is on the formulary, you can purchase the brand-name drug, but you will be responsible for the total cost. These costs will not count toward your initial coverage limit or the catastrophic coverage threshold. Please talk to your doctor about switching to generics if a generic is available and appropriate for your treatment.

How are my prescription drugs covered under BlueAdvantage and BlueChoice?
All of our plans use a formulary, or list of covered drugs. Some drugs on the formulary may be covered under the Medicare Part B portion of your coverage, depending on why you’re taking it and how you receive it. This means that your Part D copays and benefits will not apply to these drugs, even though they are listed in the formulary. Also, they will not count toward your initial coverage limit or the catastrophic coverage threshold. Examples of the types of drugs that may be subject to Part B coverage include:

  • Antigens - If prepared by a doctor and administered by a properly instructed person (who could be the patient) under a doctor's supervision
  • Erythropoietin (Epoetin alpha or Epogen®) - By injection if you have End-Stage Renal Disease (permanent kidney failure requiring either dialysis or transplant) and need this drug to treat anemia
  • Hemophilia clotting factors - Self-administered clotting factors if you have hemophilia
  • Immunosuppressive drugs - If you had a transplant in a Medicare-certified facility and were enrolled in Medicare Part A at the time. The immunosuppressive drugs must also be medically necessary to prevent or treat rejection of the transplanted organ. They must also be self-administered.
  • Inhalation and infusion drugs - Provided through a durable medical equipment supplier
  • Injectable drugs - The drug generally cannot be self-administered and your doctor provides and administers the drug to you
  • Injectable Osteoporosis drugs - If you receive Medicare home health benefits and you have a bone fracture related to post-menopausal osteoporosis
  • Oral anti-cancer drugs - If the same drug is available in injectable form
  • Oral anti-nausea drugs - If the drug is part of an anti-cancer chemotherapeutic regimen
Out-of-network/non-contracted providers are under no obligation to treat BlueAdvantage members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our member service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Medicare Supplement

What does a Medicare supplement plan cover?
Medicare supplement (sometimes referred to as Medigap) plans cover your portion of the costs for Parts A and B, such as deductibles, copayments and coinsurance. The supplement is meant to help cover what Original Medicare does not.

Are prescription drugs covered by BlueCross BlueShield of Tennessee's Medicare supplement plans?
No. If you're buying a Medicare supplement plan and want prescription drug coverage, you'll need to enroll in a separate Medicare Part D plan. Some supplement plans sold before 2006 included drug coverage and people who had already purchased those plans were allowed to keep the same coverage.

Am I eligible to purchase a Medicare supplement plan?
If you're enrolled in Medicare Part A and B, you're probably eligible to buy a Medicare supplement plan.

Does a Medicare supplement plan replace Original Medicare?
Medicare supplement plans are purchased in addition to your Original Medicare benefits.

What are the enrollment dates for Medicare supplement plans?
There are no specific enrollment dates for a Medicare supplement plan. There is a Medicare supplement Open Enrollment Period that lasts six months. It starts on the first day of the month in which you are BOTH age 65 or older AND enrolled in Medicare Part B. If you are under age 65 and enrolled in Medicare by reason of disability or End-Stage Renal Disease, there is a similar Open Enrollment Period.

Once your Medicare supplement Open Enrollment Period starts it cannot be changed. During this period you cannot be denied coverage, but preexisting condition limitations may apply.

What if my Medicare supplement Open Enrollment period is over?
You can still apply for a Medicare supplement plan after your Open Enrollment Period has expired. However, your application may be subject to medical underwriting (i.e. a review of your medical history and current health) unless you qualify under guaranteed issue rights.

You also may have the right to buy a Medicare supplement plan outside of your Open Enrollment Period if you lose certain types of health coverage. This lasts for 63 days from the date coverage ends or from the date you receive notice that your coverage will end. You must provide proof of the loss of your previous coverage. Otherwise your application may be subject to medical underwriting.

When does my Medicare supplement coverage begin?
Your coverage begins on the first day of the month after BlueCross BlueShield of Tennessee receives your completed application - unless you request a later effective date, or you enrolled prior to your Medicare Part A or B effective date.

Can BlueCross BlueShield of Tennessee cancel my Medicare supplement plan?
Medicare supplement coverage is guaranteed renewable, which means BlueCross BlueShield of Tennessee cannot cancel your policy because of your age or health. You may be involuntarily disenrolled from the plan under the following circumstances:

  • Your Medicare Part A or Medicare Part B coverage ceases.
  • You fail to pay any monthly plan premium.

Do I have to take a physical exam to enroll in a BlueCross BlueShield of Tennessee Medicare supplement plan?
No, but you may need to answer health questions during enrollment. Responses to medical questions are not required if you are enrolling during open enrollment or qualify for guaranteed issue.

Will my Medicare supplement premium change?
Your monthly premiums are based on your age as of June 1 prior to the effective date of your plan. Your monthly premiums may increase each year based on your age, in addition to any other increases in premiums required.

Do I have to use certain doctors with a Medicare supplement plan?
No. With a Medicare supplement plan, you have the flexibility to choose any doctor or hospital who accepts Medicare.

Out-of-network/non-contracted providers are under no obligation to treat BlueAdvantage members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our member service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

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