CLIENT FREQUENTLY ASKED QUESTIONS

After you have reviewed your Annual Notice of Change and you’re satisfied with the changes, you do not need to do anything. Your plan will automatically renew for next year and you do not need to sign any documentation to renew your plan.

Unless you have any additional questions about your plan or benefits, then you’re all set! However, if you do have questions, your client advisor team is available to assist. Call 877.222.1942.

Unfortunately, the donut hole exists on every Medicare plan. The donut hole is based on your prescription medications and changing your plan will not eliminate the possibility of going into the donut hole.

Some TV commercials about Medicare plans can be misleading. If you have any questions about anything you saw or are interested in any plan benefits they referenced, please give our client advisor team a call.

Our phones lines are open Monday through Friday 8a.m. – 5 p.m., and beginning October 7, Saturday from 8 a.m. – 12 p.m. You may also schedule a call with our team by calling 937.222.1942.

Your Medicare plan benefits are outlined in your Summary of Benefits, located in your plan booklet provided by your insurance company and available on your insurance company’s website. You can also call us at 877.222.1942 and we can walk through your plan’s benefit information with you. The Summary of Benefits gives you a general idea of costs for various procedures, but it is important to note that complicated medical services (such as surgeries) will only be estimates. The final costs will be based on the services billed by your provider and the allowed amounts by the plan.

No, an Explanation of Benefits is not a bill—it is simply a statement sent by a health insurance company to individuals explaining how medical treatments and/or services were paid for on their behalf. If you were to receive a bill for medical services, it would come from your provider or hospital, not from the insurance company. An insurance company will only bill you for plan premiums.

If you believe your bill is incorrect, call us for assistance. We can help guide you in the right direction and assist you in calling your insurance company or provider’s office if needed.

Once your enrollment has been processed, it can take up to two weeks for you to receive your ID card in the mail. In the meantime, we can provide you with your plan policy number that you can use until you receive the card in the mail. You can also create an online account with the insurance company and print a temporary ID card.

The fastest way to secure a new ID card is to call the insurance company or use your online member account to request a new one. When calling, many insurance companies have automated phone prompts through which you can request a duplicate ID card. It usually takes around five minutes to request a new one. You should receive the new ID card in 7-14 business days. Call our team if you need any assistance with this.

Ultimately, you must request a provider directory from your insurance company; however, we encourage clients to search online using the insurance company website which contains more current provider information than printed directories. Providers may leave or join a plan’s network at any time during the year. If you need assistance searching for a provider, call our team for assistance at 877.222.1942.

You must contact your insurance company to request plan materials such as the Evidence of Coverage, Summary of Benefits, or Formulary. You can also download the plan materials from your insurance company’s website. Contact us if you need assistance with reaching out to your insurance company.

Medicare plans grant coverage for urgent and emergency care within the United States. For all other non-emergency medical services while traveling, coverage depends on the kind of plan you have. For example, PPO plans offer some extended coverage while some HMO plans require you to stay within your plan’s service area. Please contact our team for details.

Coverage outside of the country varies depending on the plan. To confirm your travel benefits, you can refer to your plan’s Evidence of Coverage and Summary of Benefits or contact our team.

Medicare Advantage (MA) plans are based on the county you live in. If you are moving outside of your current county or to another state, please contact us to discuss your plan options. You may or may not need to change your plan depending on where you move. If you move within the same county, you only need to inform us of your new address.

The “donut hole” (or coverage gap) is a gap in prescription drug coverage. It occurs after the total cost of your medications during the year has exceeded a certain amount. Call us to discuss any questions you may have about your personal situation.

Your plan might require prior authorization for certain prescription drugs. Before your plan covers one of these drugs, your provider will need to contact your insurance company and explain why it is medically necessary for you. If a medication requires prior authorization, it will be noted on your plan’s Formulary.

A quantity limit is a cap on how much of a medication you can get in a certain timeframe. Insurance companies place quantity limits on certain drugs for safety and cost reasons. If you are prescribed more than the quantity limit, your provider will need to contact the insurance company to confirm that the additional amount is medically necessary.

In some situations, certain vaccinations may be covered. However, most provider offices are unable to bill these claims to your prescription drug plan. Typically, most have an easier time obtaining coverage by getting vaccines from a pharmacy instead of a provider’s office. If you have questions about the specifics of your plan’s benefits, call our team.

Step therapy is a type of prior authorization required by an insurance company. Specifically, it is the process of treating a medical condition with the most cost-effective medication before progressing and providing coverage for a more costly medication.

A prescription drug deductible is the amount you must pay annually before you start paying the fixed copays as outlined by your plan. Not all Medicare plans have a prescription drug deductible. You can refer to your Summary of Benefits to determine your deductible and copay amounts.

Generally speaking, Part B covered medications include those given by a doctor in a medical office or hospital setting; they are determined medically necessary by a provider. Part D medications are generally maintenance medications that you take yourself (the type you pick up from the pharmacy). Please visit Medicare’s website to learn more.

If you are having trouble paying for medication costs, you may have options. If the medication is not listed on your formulary, it is possible for your provider to request a formulary exception from the insurance company by providing medical necessity. Another option is to contact the Social Security Office to determine your eligibility for a federal program called Extra Help. For more tips on how to save on medication costs, watch this video. If you would like assistance or have further questions, contact our team.

During a hospital visit, any routine prescriptions you need that are given by the hospital are considered self-administered drugs. These medications are typically not covered in your hospital co-pay, unless they are required for the hospital services you are getting. You will most likely be billed for the full amount. Once you have paid your bill, you are able to request reimbursement from the Part D portion of your plan through a form called a Prescription Drug Reimbursement Claim Form. We recommend that you check the hospital’s policy on bringing in your own medications, which may allow you to avoid these types of bills. If you find yourself in this situation, contact our team to learn more.

A drug deductible is the amount of money you pay for certain medications before your plan begins to cover some of the cost. Deductibles are primarily understood as the amount of money you must spend out of pocket first before your insurance kicks in. After you reach your deductible, you usually pay a flat rate (copayment) or percentage (coinsurance) of the medication cost

If you’ve previously had drug coverage on your Medicare plan, you may be familiar with the concept of a drug deductible. Not all Medicare plans have a drug deductible but plans that do begin calculating it at the beginning of each calendar year. The deductible dollar amount may also change from year to year.

In some cases, the deductible will apply to all medications. But it’s very common for the deductible to apply only on certain drug tiers. In these situations, lower-cost medications will often be exempt from the deductible. The deductible usually applies to more expensive medications, such as tier 3, 4, or 5 medications.

A copay is a fixed dollar amount set by the insurance company that you are responsible for paying. In most cases you begin to pay copays after your plan’s deductible is met. It is important to keep in mind that deductibles do not always apply to all drug tier levels and some plans do not have drug deductibles.

Coinsurance is a percentage of the drug cost that you are responsible for paying. The full cost of medications fluctuates, which means this amount may differ throughout the year. Like copays, you may also have to satisfy your plan’s deductible before you begin paying your coinsurance on medications. Coinsurances are usually applied to higher tier levels, such as tiers 4 or 5. It is important to refer to your plan’s formulary and Summary of Benefits when estimating what you will be responsible for paying at the pharmacy.

Medicare plans with prescription drug coverage organize medications into different price categories called “tiers.” Medicare plans can have as many as 4 or 5 tiers and generally, drugs in the lower tiers have lower costs while drugs in higher tiers have higher costs. For example, a tier 1 drug will usually have lower copays than a tier 3 drug. But it is important to note that this is not always the case—it is up to the individual insurance company to determine the benefits of a given tier level. For this reason, we advise our clients to be aware of what tier their medications fall into and what the copay or coinsurance will be for that tier level.

It is important to know if your Medicare plan includes a Part D deductible. If a deductible is included, it is important to know which tiers are affected by the deductible. Your plan will list which tiers are affected by the deductible in your Evidence of Coverage. The deductible amount must be approved by the Centers for Medicare and Medicaid Services (CMS).

If your plan has a deductible, the deductible needs to be satisfied before your insurance company will pay anything toward your medications. Once the deductible is met, you will begin paying the copays or coinsurances that are associated with the tier level of your medication. On some plans, the deductible only applies to specific drug tier levels as opposed to all tiers.

During Medicare’s Open Enrollment Period (OEP), Jan. 1 – Mar. 31, anyone on a Medicare Advantage (MA) plan can enroll in a different MA plan or disenroll from their current MA plan and return to Original Medicare. Individuals can only make one change to their plan during OEP. If a plan change is made, the new plan will go in effect the first of the following month.

Medicare’s Annual Enrollment Period (AEP) is for all individuals on any type of Medicare plan. AEP is from Oct. 15 to Dec. 7 each year. During this time, you can review your current Medicare plan and explore others that may better fit your needs or budget. If you choose, you can enroll in a new plan for the upcoming year. It is important to note any needs that may require an adjustment in coverage throughout the year, that way we can assist you once AEP comes.

When certain life events happen, Special Enrollment Periods (SEPs) allow you to make changes to your medical or prescription drug coverage. Some examples of qualifying life events are moving to a different location or losing other insurance coverage. If you would like to know more about SEPs, please reach out to us.