A Healthy CollaborationSM

Frequently Asked Questions: Medicare Information

Q: What is a PPO (Preferred Provider Organization)?

PPO plans are designed to reduce the cost of healthcare by contracting with certain doctors, labs, and hospitals to provide care at a discounted rate for its members. You will save the most when you utilize our comprehensive network of care providers, but a PPO will also pay a portion of your healthcare costs if you choose a doctor or hospital that isn’t in the network, but agree to accept the plan’s payment terms and conditions.

Q: With a PPO, is my choice of doctors limited?

No. You may go to any doctor, specialist, or hospital anywhere in the U.S. that agrees to accepts the plan’s payment terms and conditions, though you will enjoy optimum savings when you choose a doctor within your local Today’s Options PPO network.

Q: What is an HMO (Health Maintenance Organization)?

HMO plans are a type of Medicare Advantage Plan (Part C) that includes all your Part A (hospital insurance) and Part B (medical insurance) benefits. HMOs also cover additional benefits, like extra days in the hospital, and dental and vision care. With most HMOs, you can only go to doctors, specialists, or hospitals in the plan’s network, except in an emergency. That allows us to offer you significant savings over Original Medicare.

Q: How does an HMO work?

By working with a select team of doctors and hospitals, HMOs are able to keep costs low. When you join an HMO, you may go to any doctor or hospital that is included in the network. In addition, you will be asked to choose a primary care doctor. This doctor will coordinate all of your medical care, including choosing specialists when additional care is needed. However, with the exception of emergency situations, if you choose a doctor or medical facility that is not included, you will be responsible for all costs.

When you join an HMO, you’re still enrolled in the Medicare program and entitled to all medically necessary healthcare services that Medicare covers. However, as a HMO member, you will enjoy deductibles, co-payments, and coinsurance amounts that may be substantially lower than those under Original Medicare.

Q: How is a PPO different from an HMO?

PPOs and HMOs both offer members guaranteed lower costs on doctor visits, hospital stays and other services when the member chooses a network provider. The difference lies in the amount you pay out of pocket when using an out-of-network provider. You are liable for 100 percent of the cost when choosing a provider that is not in your HMO network. With a PPO, your plan will still cover a percentage of the cost when you choose an out-of-network provider.

Q: How does a Medicare Advantage PFFS (Private Fee-for-Service) plan work?

When you enroll in a Medicare Advantage PFFS plan, you are still part of the Medicare program, and still entitled to all medically necessary healthcare services that are covered by Medicare. As a Today’s Options member, however, you’ll enjoy the added advantages of low co-payments for doctor and hospital visits, plus all the built-in advantages that promote your health, safeguard your right to choose and save you money. That means you have the choice to see any doctor, specialist or hospital in the U.S. that accepts the terms and conditions of the Today’s Options plan.

Q: Am I eligible for a Medicare Part D Prescription Drug Plan?

You must be entitled for Medicare benefits under Medicare Part A and/or enrolled in Medicare Part B to be eligible for our Part D plans. Please note that you can only be enrolled in one Medicare prescription drug plan at a time.

Medicare beneficiaries are entitled to enroll in or switch their Medicare Prescription Drug Coverage (Medicare Part D) between November 15 and December 31, for an effective date January 1st. There are other times when you may be able to sign up or switch prescription drug plans.

There are other times when you may be able to sign up or switch prescription drug plans. If you are turning 65 and are new to Medicare, you can enroll in a plan up to three full months before your birth month and up to three months after. If you are enrolled in Medicare and Medicaid, you can switch at any time.

Q: What drugs are excluded from the Medicare Part D Prescription Drug Plans and Medicare Advantage Prescription Drug Plans (MA-PD)?

The drugs that are excluded by Medicare are:

  • Medications used to treat anorexia, weight loss, or weight gain
  • Medications used to promote fertility
  • Medications used for cosmetic purposes or hair growth
  • Medications used to treat erectile dysfunction
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparation
  • Non-prescription drugs

Outpatient medications for which the manufacturer requires that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale.

In addition, if a medication is covered by Medicare Parts A or B, it cannot be covered under Part D (Medicare Advantage Plans with Prescription Drug or Medicare Prescription Drug Plans). Some examples of Parts A or B medications include: diabetic test strips, injectables solely administered in the physician’s office and medications administered in the hospital. Also, each Medicare Advantage Prescription Drug Plan and Medicare Prescription Drug Plan may have its own specific exclusions.

Q: What if I don’t become eligible for Medicare until after December 31 of this calendar year?

No problem! Medicare will inform you of the dates of your seven-month open enrollment period, which is the same as your enrollment period for Medicare.

Q: Can I switch Medicare Advantage or Medicare Part D plans if I’m already enrolled in another Medicare prescription drug plan?

Yes. Generally speaking, most people are allowed to switch Medicare drug plans between November 15 and December 31 each year for an effective date of January 1st.

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