SecureChoice (PPO) - Ohio/West Virginia

  1. Do I need Medicare A & B to enroll into your Medicare Advantage Plan with Part D prescription drug coverage?

    Yes. To be eligible to elect a Medicare Advantage Plan, an individual must be entitled to Medicare Part A and enrolled in Part B, and must be entitled to Medicare Part A and Part B benefits as of the effective date of coverage under the plan. You must continue to pay the monthly Medicare Part B premium.

  2. When can you enroll in a Medicare Advantage Plan?

    Enrollment into a Medicare Advantage Plan is generally for the entire plan year. Once you enroll, you may only leave the plan or make changes to it at certain times of the year when an enrollment period is available or under certain special circumstances.

    Initial Coverage Election Period (ICEP):

    The ICEP is the period during which an individual newly eligible for Medicare Advantage may make an initial enrollment request to enroll in a Medicare Advantage Plan. This period begins three months immediately before the individual’s first entitlement to both Medicare Part A and Part B and ends on the later of: 1) The last of the month preceding entitlement to both Part A and Part B; or, 2) The last day of the individual’s Part B initial enrollment period. (The initial enrollment period for Part B is the seven month period that begins three months before the month an individual meets the eligibility requirements for Part B, and ends three months after the month of eligibility.)

    Annual Election Period (AEP) October 15 – December 7:

    During the AEP, Medicare Advantage eligible individuals may enroll or disenroll from a Medicare Advantage Plan. If you wish to enroll in a new Medicare Advantage Plan, like those offered by The Health Plan for January 1, you can do so by changing your plan during the Annual Election Period (AEP). This Annual Election Period runs from October 15 – December 7 of each year. Changes will take effect on January 1.

    Medicare Advantage Open Enrollment Period (MA OEP) January 1 - March 31

    During the MA OEP, Medicare Advantage plan enrollees may enroll in another Medicare Advantage plan or disenroll from their Medicare Advantage plan and return to Original Medicare. Individuals may make only one election during the MA OEP. Individuals may add or drop Part D coverage during the MA OEP. Individuals enrolled in either MA-PD or MA-only plan can swith to: MA-PD, MA-only, or Original Medicare (with or without a stand-alone Part D plan). The effect date for an MA OEP election is the first of the monthy following receipt of the enrollment request.

    NOTE: The MA OEP does not provide an opportunity for an individual enrolled in Original Medicare to join a MA plan. It also does not allow for Part D changes for individuals enrolled in Original Mediare, including those enrolled in stand-alone Part D plans. The MA OEP is not available for those enroleed in Medicare Savings Accounts or other Medicare health plan types (such as cost plans or PACE).

    Special Election Period (SEP):

    Special Election Periods constitute periods outside of the usual ICEP, AEP, or MADP when an individual may elect a plan or change their current plan election. There are various types of SEPs, including (but not limited to) SEPs for: beneficiaries who receive assistance under Title XIX (Medicaid), those who receive Extra Help with Part D drug costs (LIS), those whose current plan terminates, who change residence, who would like to join a 5-Star rated plan and those who meet “exceptional conditions."

  3. Are there pre-existing conditions?

    Except under special conditions, an individual is not eligible to elect a Medicare Advantage Plan if they have been medically determined to have end-stage renal disease (ESRD).

  4. Do I give up my Medicare by joining your Medicare Advantage Plan?

    No. You keep your Medicare, but The Health Plan will issue you an identification card to use during visits to your physicians or hospital. Keep your Medicare card in a safe place if you decide to go back to Original Medicare.

  5. What if I move out-of-the-area?

    Our contract with Medicare requires you to live inside our service area. Medicare allows you to leave our service area for no more than six consecutive months. If you are moving outside of the service area you must tell us in writing so we can disenroll you. You will then be covered under Original Medicare.

  6. What if I already belong to another Medicare Advantage Plan?

    If you choose to enroll into one of The Health Plan Medicare Advantage Plans, your coverage from your current Medicare Advantage Plan will automatically be terminated. Medicare only allows you to be enrolled in one Medicare Advantage Plan at a time.

  7. Do I need to choose a primary care physician (PCP) and can I change my PCP at any time?

    No, you are not required to choose a PCP on the SecureChoice PPO Option II or SecureChoice PPO Capitol Plan

  8. What is the difference between a Medigap Policy and a Medicare Advantage Plan?

    A Medigap policy is Medicare Supplement Insurance sold by private insurance companies to fill the “gaps" in Original Medicare Plan coverage. These policies help pay some of the health care costs that the Original Medicare Plan does not cover. Whatever Medicare does not cover typically a Medigap plan will pick up

    Medicare Advantage Plans are health options that are part of the Medicare program. If you join one of these plans, you generally get all of your Medicare-covered health care through that plan with lower copayments. You may have to see doctors that belong to the plan or go to certain hospitals to get service. This coverage can include prescription drug coverage.

  9. What is the difference between a Medical Emergency and Urgently Needed Care?

    The two main differences between "urgently needed care" and a “medical emergency" are in the danger to your health and your location. A “medical emergency" occurs when you reasonably believe that your health is in serious danger, whether you are in or outside of the service area. “Urgently needed care" is when you need medical help for an unforeseen illness, injury, or condition but your health is not in serious danger and you are generally outside of the service area. Under unusual and extraordinary circumstances, care may be considered urgently needed and paid for by The Health Plan when you are in the service area, but the provider network is temporarily unavailable or inaccessible.

  10. What is the difference between Traditional Medicare and Medicare Prescription (Part D) coverage?

    Original Medicare Part A and B covers hospitalization and outpatient medical services. Prescription drug coverage was not included in the Original Medicare plan. The Medicare Part D Prescription Plan was started in January of 2006 which allows individuals to receive a prescription drug benefit through the Medicare program. Medicare Part D prescription drug coverage is administered through private insurance companies and may or may not be included in a Medicare Advantage Plan.

  11. What happens to my Medicare card if I enroll in a Medicare Advantage Plan?

    You can keep your Medicare card. The Health Plan card will be sent to individuals who join our Medicare Advantage Plan to be used when receiving medical, vision and/or prescription services.

  12. What is Creditable Coverage?

    This is coverage that is on average, at least as good as the standard Medicare Part D prescription drug coverage as outlined by the government.

  13. What if I already receive prescription drug coverage as part of my employer’s retiree benefits?

    You decide what is best for you. If an employer or union offers prescription drug benefits, you should compare the plan and costs with those offered under The Health Plan prescription drug plans. It is an employer’s responsibility to inform their Medicare eligible retirees/employees if the prescription drug plan offered is considered to be creditable coverage. This means the coverage is on average, at least as good as the standard Medicare Part D benefit

    Note: If your retiree plan is not considered creditable coverage and you choose not to purchase a Medicare Part D Prescription Drug Plan, you may have to pay more each month (a penalty) if you want to join a Medicare Part D Prescription Drug Plan later. Also, if your employer coverage has a Medicare Part D Prescription Drug Plan, your enrollment in The Health Plan Medicare Advantage Plan will automatically cancel your employer coverage even if you chose one of our plans without Part D prescription drug coverage.

  14. Will my prescriptions be covered if I have coverage through the Veteran’s Administration (VA)?

    VA benefits will not be affected. Medicare beneficiaries who currently have prescription drug benefits through the VA will be able to continue to obtain their prescriptions through the VA coverage.

  15. What if I am traveling and need to fill a covered prescription?

    You can fill a prescription at any of the pharmacies participating in The Health Plan network, no matter where they are in the United States. Also, you may choose to use our mail order service offered through Express Scripts.

  16. Are prescriptions covered in Canada?

    No. Only drugs sold within the United States are covered under the Medicare Prescription Drug Plan.

  17. To help save money do you offer Prescriptions-by-Mail?

    Yes. If you take medications on an ongoing basis, using mail order to receive your prescriptions will result in a cost savings for you. You can receive a 90-day supply of most of your covered medications for two copays instead of three and using the mail order service could result in a savings for the actual cost of the medication.

  18. What are your drug copays and do you offer coverage through the gap?

    The Health Plan SecureChoice PPO 2020 prescription drug copays are:

    SecureChoice PPO - Option II and SecureChoice PPO Capitol Plan

    Preferred Generic (Tier 1)

    PREFERRED/STANDARD PHARMACY NETWORK

    • $3/$13 for a one month (30-day) supply at the retail pharmacy
    • $9/$39 for a 90-day supply at the retail pharmacy
    • $0/$0 for a 90-day supply through mail order
    • Not all drugs on this tier are available at this extended day supply. Contact the plan for more information.

    Non-Preferred Generic (Tier 2)

    PREFERRED/STANDARD PHARMACY NETWORK

    • $10/$20 for a one month (30-day) supply at the retail pharmacy
    • $30/$60 for a 90-day supply at the retail pharmacy
    • $0/$0 for a 90-day supply through mail order
    • Not all drugs on this tier are available at this extended day supply. Contact the plan for more information.

    Preferred Brand (Tier 3)

    PREFERRED/STANDARD PHARMACY NETWORK

    • $47/$47 for a one month (30-day) supply at the retail pharmacy
    • $141/$141 for a 90-day supply at the retail pharmacy
    • $94/$94 for a 90-day supply through mail order
    • Not all drugs on this tier are available at this extended day supply. Contact the plan for more information.

    Non-Preferred Brand (Tier 4)

    PREFERRED/STANDARD PHARMACY NETWORK

    • $100/$100 for a one month (30-day) supply at the retail pharmacy
    • $300/$300 for a 90-day supply at the retail pharmacy
    • $200 for a 90-day supply through mail order
    • Not all drugs on this tier are available at this extended day supply. Contact the plan for more information.

    Specialty Drugs (Tier 5)

    PREFERRED/STANDARD PHARMACY NETWORK

    • 31% for a one month (30-day) supply at the retail pharmacy
    • 31% for a one month (30-day) supply at mail order
    • A long term supply is not available for specialty drug (Tier 5) prescriptions.

    You will stay in the yearly deductible stage until you have paid $100 for your brand name or Tier 3, 4 and 5 drugs. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 25% the plan’s cost for covered generic drugs until your covered costs total, $6,350, which is the end of the coverage gap. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach, $6,350, you pay the greater of 5% of the cost or $3.60 copay for generic (including brand drugs treated as generic) and a $8.95 copayment for all other drugs.

  19. How can I find out if my drugs are covered?

    Go to our website, www.healthplan.org/medicare for more information or call our office at 1.877.847.7915

  20. Do I need a Medicare Prescription Drug Plan?

    The Medicare Part D prescription drug program is completely voluntary. If you want Medicare Part D prescription drug coverage, you can choose to enroll with The Health Plan. There could be a penalty if you do not join during your initial enrollment period. The penalty is 1% for every month you were eligible but did not enroll. The exception is if you have creditable coverage, meaning you have a plan that is on average, at least as good as the standard Medicare Part D prescription drug coverage.

  21. What is my monthly premium?

    The 2020 monthly premiums for The Health Plan’s Ohio/West Virginia Medicare Advantage Plans are indicated in the following tables:

    Ohio/West Virginia The Health Plan SecureChoice PPO Option II The Health Plan SecureChoice PPO Capitol Plan
    2020 Premium 94.00 $66.00
    Part C Medical Coverage YES YES
    Part D Prescription Coverage YES YES
    Vision Coverage YES YES
    Fitness Benefit (Silver Sneakers) YES YES

    If you are currently receiving extra help with your prescriptions through the government, the Medicare Part D premium amount that you pay as member of SecureChoice PPO plan will vary based on Medicare guidelines.

    Premiums, copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

  22. Is Extra Help available for my prescriptions?

    If you have limited income and resources you may qualify for extra help to cover prescriptions in one of two ways:

    • You automatically qualify for extra help and do not need to apply. This applies if you have full coverage from a state Medicaid program, get help from Medicaid paying your Medicare premiums or get Supplemental Security Income Benefits. Medicare will mail a letter to those who automatically qualify for extra help.
    • You apply and qualify for extra help. If you think you qualify, call Social Security at 1.800.772.1213 or visit their website at www.socialsecurity.gov. You may also be able to apply at your state Medicaid office. After you apply you will be notified by mail letting you know if you have been accepted and what to do next.
  23. Do I have any deductibles to pay?

    If you enroll in the SecureChoice PPO plan, all of your Medicare deductibles will be covered.

  24. Is there an out-of-pocket maximum?

    Yes, the annual out-of-pocket maximum for SecureChoice PPO Option II is $6,700 in-network/ $10,000 in and out-of-network combined. The annual out-of-pocket maximum for the SecureChoice PPO Capitol Plan is $4,500 in-network/$10,000 in and out-of-network combined. The annual out-of-pocket maximum is the limit to how much you may have to pay out-of-pocket in the form of copays and/or coinsurance amounts for covered health care services each year. Once your total costs for covered health care services, excluding outpatient drugs, reaches the specific plan’s annual out-of-pocket maximum, then you will not have to pay for covered medical services for the remainder of the calendar year. You will still continue to pay for your Part D prescription drugs.

  25. How do I pay my monthly premium?

    Your monthly premium is paid to The Health Plan. You have three payment options to choose from:

    • Get payment coupons and pay directly by cash or check each month.
    • Have your monthly premium automatically deducted from a checking or savings account.
    • Automatic deduction from your monthly Social Security benefit check