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 (ESRD).
  • 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 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. Please call our customer 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 plan, will I lose my Medicare coverage?
No. Medicare Advantage plans like BlueAdvantage are part of the Medicare program and are administered by a private insurance company such as BlueCross under contract with Medicare.

Does BlueAdvantage cover the same services as Original Medicare?
Yes. With BlueAdvantage, you get the same coverage you get with Original Medicare - plus some extra benefits, too.

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 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 members.

Do I have to choose a Primary Care Provider (PCP)?
Yes. Having a PCP is an important part of managing your health. Our BlueAdvantage 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.

Do I need a referral to see a specialist?
BlueAdvantage members are not required to have a referral to see a specialist.

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 Medicare Advantage Open Enrollment Period (January 1 to March 31). During this time, Medicare Advantage plan enrollees can disenroll from their Medicare Advantage plan and return to Original Medicare or make a one-time switch to a different Medicare Advantage plan. If you decide to go to Original Medicare, you will need to purchase a standalone Part D prescription drug plan to avoid a Part D late enrollment penalty.

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 monthly premiums or benefits change next year?
BlueAdvantage 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 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 plan if I am traveling?
With BlueAdvantage, you are free to seek care from any health care provider that accepts Medicare payments. However, you must present your BlueAdvantage ID card before you receive services and you will pay the out-of-network cost share amounts.

What are my payment method options?
You have several.

  • Monthly Billing Statement
  • Bank Draft
  • Social Security Deduction

Is there a grace period if I do not pay my premiums?  
Yes, you have a grace period of three calendar months.

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 ends April 30.

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 for the Annual Election Period (AEP), or between January 1 - March 31 for the Open Enrollment Period (OEP), 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) (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.

Out-of-network/non-contracted providers are under no obligation to treat BlueAdvantage members, except in emergency situations. Please call our customer 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 on the forms and documents page.

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

  1. Ask your doctor if a drug on the formulary would work for you. 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.
  4. You may also choose to pay cash for the medication and not request an exception and reimbursement.

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 have two options. As described above, you may request a formulary exception for a brand name drug that is not on our formulary. Or 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?
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:

  • Drugs that usually aren’t self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services
  • Drugs you take using durable medical equipment (such as nebulizers) that were authorized by the plan
  • Clotting factors you give yourself by injection if you have hemophilia
  • Immunosuppressive drugs, if you were enrolled in Medicare Part A at the time of the organ transplant
  • Injectable osteoporosis drugs, if you are homebound, have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis, and cannot self-administer the drug
  • Antigens
  • Certain oral anti-cancer drugs and anti-nausea drugs
  • Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, topical anesthetics, and erythropoiesis-stimulating agents (such as Epogen®, Procrit®, Epoetin Alfa, Aranesp®, or Darbepoetin Alfa)
  • Intravenous Immune Globulin for the home treatment of primary immune deficiency diseases

Out-of-network/non-contracted providers are under no obligation to treat BlueAdvantage members, except in emergency situations. Please call our customer 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.

 

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