Frequently Asked Questions about Medicare Advantage Plans
What is Medicare Advantage?
Medicare Advantage is s Medicare program gives Medicare beneficiaries more options to consider as they choose a Medicare health plan. Anyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease (certain exceptions may apply). Medicare Advantage plans (MA-PD) cover Medicare Parts A & B services and Part D (Pharmacy).
Medicare Part A is traditional Medicare hospital insurance that pays for inpatient hospital admissions, care in a skilled nursing facility, hospice care, and some home health care.
Medicare Part B is traditional Medicare medical insurance that helps pay for doctors, outpatient hospital care, durable medical equipment, and some medical services not covered by Part A.
Medicare Part D is the Medicare insurance that helps pay for pharmacy and medication services.
Why would I want to choose a Medicare Advantage (MA-PD) plan?
The advantages to choosing a Medicare Advantage Plan are:
- There are more plan choices to consider;
- Most MA-PD plans offer benefits not paid for by traditional Medicare;
- There is usually a reduction in out-of-pocket costs through lower premiums, lower co-pays, and lower deductibles;
- MA-PD plans generally are more proactive in keeping its members healthy;
- MA-PD plans cover prescription drugs, with lower premiums and co-pays; and,
- MA-PD plans have programs that improve the quality of care provided to its members.
If I am covered by an employer sponsored health plan, would I benefit from joining a Medicare Advantage plan?
It is possible that you could lower your out of pocket expenses for health care by joining an MA-PD plan. You should contact your employee benefits manager to find out more information about whether a Medicare Advantage plan would benefit you.
What are some potential disadvantages of the new program?
Some of the potential drawbacks to joining an MA-PD plan include:
- Services provided in MA-PD plans are “managed”, resulting in a system of care that is not as flexible for the member as is traditional Medicare;
- Not all medical providers are contracted with the MA-PD plan, limiting you to physicians in the plan’s network;
- Your current physician may not have a contract and is not in the network;
- You are not free to self refer to any “out of network” provider without prior authorization; if you go out of network without prior health plan approval, you will be responsible for those expenses;
- Referrals generally require an approved authorization from your primary physician and the plan;
- Sometimes all the “rules” for getting services can be confusing and frustrating for the member;
- If a hospital or health care provider does not participate in the Medicare program, you can not be referred to that provider; and,
- Once you have chosen an MA-PD plan, you are “locked” into the plan and can not change plans until the next benefit year.
Do Medical Management rules apply to Medicare Advantage Plans?
Generally, Medical Management rules regarding referrals apply. Providers are encouraged to obtain an Authorization Determination for selected services outlined by the Plan. Authorization Determinations are performed to review benefit coverage, medical necessity, and appropriateness before services are rendered. Claims submitted for services that were not approved are reviewed retrospectively for appropriateness and coverage. Except for emergencies, it is important to contact the health plan to determine requirements prior to receiving non-emergency services.
Can I use any hospital or provider for services?
If you have an emergency medical condition, you may seek treatment at the nearest hospital or emergency room, regardless of the plan coverage. For non-emergency care use hospitals and health care providers in your area that are contracted with your plan.
Will I have the same hospital benefits with Medicare Advantage that I had with traditional Medicare?
The hospital services covered under traditional Medicare will be the same. However, there may be limits on which hospitals, doctors, or pharmacies you use. Out of pocket expenses are usually less than with traditional Medicare. You may even have additional coverage for dental and vision, depending on the plan you choose. It is important to check with your MA-PD plan to see what benefits and limitations you may have.
Am I covered if I am out of the service area?
Your care is covered if you have a medical emergency or urgently need health care services any where inside the United States or abroad. A “medical emergency” is defined as such when you believe that your health is in serious danger. Medical emergencies include severe pain, a major injury, a sudden illness, or a medical condition that is quickly getting worse. “Urgently needed” care is defined as when you need medical care for an unforeseen illness, injury, or condition, but your health is not in serious danger.
When you receive emergency or urgently needed health care services from a provider who is not part of our network, you are responsible for paying your cost sharing amount. You should instruct the provider to bill our health plan for the balance of the payment they are due. If you have received a bill from the provider, please send that claim to GEMCare Health Plan, 4500 California Avenue, Ste. 100, Bakersfield, Ca 93309 to the attention of the Member Services Department, so we can reimburse the provider what they are owed.
What services can I receive without getting an authorization approved?
Most services are provided or arranged by your primary physician. You may get the following services without a referral or approval in advance. You will still be responsible for all co-pays or your share of any non-covered expenses.
- You may self refer to a gynecologist for a routine annual woman’s examination. This examination includes a breast exam, a pelvic examination and a PAP smear.
- Routine screening mammograms are covered, depending on age and history, and require a referral slip to an approved radiology service, but not prior approval.
- Flu shots and pneumonia vaccinations (Pneumovax) are covered provided you obtain them from a contracted plan provider.
- Emergency and urgently needed services are covered and do not require prior authorization (see above).
- Kidney Dialysis services outside the Plan’s service area are covered without authorization. If possible, please call us before you leave the service area so we can help arrange for you to have maintenance dialysis while outside the service area.
When you receive care outside the service area without approval, you will be responsible for all expenses. You will usually pay a higher cost for the care since you will get your care from non-contracted providers. If you have questions about your care and medical cost responsibilities when you travel, please call Member Services at 1-877-697-2464 (TTY/TTD users call 1-888-833-9312).
Are Hearing Services covered?
Except in unusual cases, you pay 100% of the costs for routine hearing exams and hearing aids. If you require a diagnostic hearing exam, you pay a $10 co-payment for each Medicare covered diagnostic hearing exam.
How do I complain or file a Grievance?
If you have a complaint or a concern, you or your representative may call member services at 1-877-697-2464 or 661-716-8800 and verbally state your concern or complaint. At the time of the call every attempt will be made to resolve the issue while you are on the phone.
In the event that your concern or complaint is related to quality of care or if the complaint can not be resolved over the phone, then we will ask you to formally file a grievance. This process can be done over the phone or by mail. You will be given instructions about filing the grievance and an explanation of the process and the time lines for resolution of your complaint.
What types of problems or concerns might lead to filing a grievance?
Common problems that lead to filing a grievance include:
- Issues related to the service you receive by providers;
- Rude behavior by providers or staff;
- Problems related enrollment or disenrollment;
- Disagreements with a denial for requested services;
- Prescription and pharmacy issues;
- Problems with access to doctors and appointments;
- Problems with waiting;
- Problems with your understanding of what is happening
What do I do if I need financial assistance?
People with limited income and resources may qualify for extra help. The amount of assistance depends on your financial circumstances. There are 2 situations where you can obtain assistance:
- You automatically qualify for assistance if:
- You have full coverage from a state Medicaid (Medi-Cal) program;
- You are receiving assistance from Medicaid in paying your Medicare premiums (Medicare Savings Program); or,
- You are receiving Medicare Supplemental Security Income benefits.
- You may apply to qualify for extra help if:
- You believe you have a low yearly income; and,
- You believe you do not have enough financial resources.
If you think you may qualify and wish to apply for assistance, call Social Security at 1-800-772-1213 (TTY users should call 1-800-325-0778), visit your local Social Security Office, or visit the web site www.socialsecurity.gov. You may also apply at your State Medical Assistance (Medi-Cal) office.
Available in Kern County. GEMCare Medicare Plus is a Medicare Advantage Plan offered by GEMCare Health Plan Inc., a Medicare Advantage Organization that contracts with the federal government. GEMCare Medicare Plus is available to persons who reside in the service area and are entitled to Medicare Part A and enrolled in Part B, including those with Medicare based on entitlement to Social Security Disability Benefits. You must continue to pay your Medicare Part B premiums if not otherwise paid for under Medicaid or by another third party. If you obtain routine care from out-of-plan providers neither Medicare nor GEMCare Health Plan will be responsible for the costs. Medicare beneficiaries may be enrolled in only one Part D plan at a time.