My Pharmacy Benefits

2014 Open Enrollment Frequently Asked Questions (FAQs)

Medicare Primary Options

What are Medicare Advantage plans?
Medicare Advantage plans are another Medicare health plan choice. They may be an individual or group product. Private companies contract with Medicare to provide Medicare Part A and Part B coverage. They may also include Medicare Prescription Drug Coverage and other benefits/services not typically found in Medicare. These plans must cover all of the same services that original Medicare covers. Members must already have Medicare Part A and Part B to enroll in a Medicare Advantage plan and continue to pay the Part B premium.
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When will I be able to find out more details about the Group Medicare Advantage plans?
The State Health Plan sent a mailer to members in August that included additional information. In an effort to inform Medicare Primary members about the Group Medicare Advantage options, the Plan will also conduct Medicare Outreach Events during September and October. The dates, times and locations for these meetings are posted on the Plan's website and were included in the August mailer.
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Why are we being automatically enrolled into the plan?
The State Health Plan found the Group Medicare Advantage plans to be a valuable plan choice for members. They will allow members to receive help with maintaining and improving their health through programs not typically provided through traditional State Health Plan coverage, such as fitness programs through SilverSneakers and case and disease management programs.
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My friend was automatically enrolled in the Unitedhealthcare (UHC) plan and I am enrolled in the Humana plan. How did the State make this choice for me?
State Health Plan Medicare Prime retirees were split 50/50 by state/ZIP code between the two MAPDP carriers. However, you do have the option to switch to any of the other available plan options during the open enrollment period that occurs from October 1 through November 15, 2013.
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When will I need to make a decision and enroll?
Enrollment for the benefit period beginning January 1, 2014, will take place October 1 — November 15, 2013. It is very important that you take action and enroll in the plan of your choosing. If you do not make a benefit plan selection, you will be automatically enrolled into a Group Medicare Advantage Base plan with a $0 premium for retiree coverage and will not be able to change your benefit plan until the next enrollment period.
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Why should I choose SHP's Group Medicare Advantage over an Individual Medicare Advantage Plan?
Group Medicare Advantage plans available through the State Health Plan will be Preferred Provider Organization (PPO) plans with an open network. Your copays will be the same whether you go to an in-network or out-of-network provider. Any provider that accepts Medicare and your plan of coverage will be in the network. These plans will be as good if not better than your current coverage and will include a zero dollar premium on Base plans for retiree coverage, an open network, prescription drug plan with coverage in the gap, access to several health management programs and SilverSneakers®.
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If I select one of the Group Medicare Advantage plans will I have to use a network provider?
The Medicare Advantage plans will include an open network, which means that any provider that is willing to accept Medicare should accept this plan. That means that even if your doctor is not in Humana's or UHC's network of providers, they can still treat you and file a claim with the Medicare Advantage plan you selected. Your copay or coinsurance costs, otherwise known as your out-of-pocket costs, will be the same as if you had seen a Humana or UHC provider.
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Do I lose any Medicare rights and protections by electing one of the Medicare Advantage plans?
No, under all Medicare Advantage plans, members will have the same rights and protections provided under Original Medicare including the right to appeal.
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My provider will not contract with any Medicare Advantage plans. I do not want to change providers. What are my options?
Your provider can still treat you and file a claim with the selected Medicare Advantage plan. They do not have to contract with the Medicare Advantage plans as long as they participate in Original Medicare. The Medicare Advantage plans have been conducting an aggressive Provider Outreach Campaign during the past few months to educate providers in North Carolina on the changes for the State Health Plan.
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I have coverage through Tricare for Life. Will enrollment into a Medicare Advantage plan have an effect on my Tricare insurance?
If you have coverage under Tricare for Life and enroll into Medicare prescription drug coverage, the Medicare plan will trump Tricare for Life. This means the Medicare plan would be primary to Tricare and any prescriptions would have to be submitted through the Medicare Advantage plan first and any prescription copays associated with the Medicare Advantage plan would have to be paid.
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Will I have other options if I do not want to enroll in a Medicare Advantage plan?
Members will still have the option to enroll in the retiree premium free Traditional 70/30 Plan. Enrollment into this option will include the traditional State Health Plan pharmacy coverage.
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Why is Medigap not being offered?
The Board of Trustees for the State Health Plan looked into various options for the Plan's Medicare Primary retirees. After careful consideration it was determined the best value for members and the Plan would be the offering of Group Medicare Advantage plans.
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Who pays the provider for the services that I receive?
Medicare pays the Medicare Advantage plans a monthly fixed amount for each Medicare Advantage member enrolled in their plans. In return, the private insurance carriers pay the provider and administer the Medicare Part A and Part B benefits along with value added benefits and services that original Medicare does not cover.
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Is the 80/20 plan being offered to the Medicare Primary retirees?
No. The Group Medicare Advantage plans being offered provide benefits that are comparable to the benefits under the 80/20 plan. The Traditional 70/30 plan will be offered to Medicare Primary retirees at no premium cost for the primary retiree.
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What is the difference between the State Health Plan Group Medicare Advantage Plans and individual Medicare Advantage Plans that are available to anyone on Medicare?
The State Health Plan has worked with Humana and UnitedHealthcare in developing the Group Medicare Advantage plans being offered to members to provide greater coverage for lower costs than traditional PPO coverage or individual Medicare Advantage Plans. The Group Medicare Advantage plans will all include Medicare prescription drug coverage with no gap in coverage (no "donut hole") plus an open network allowing members to see in- or out-of-network providers with no increase in their out-of-pocket costs (copays/coinsurance will remain the same). Traditional PPO coverage and individual Medicare Advantage plans typically have higher costs for individuals who seek care with out-of-network providers. Further, under individual Medicare Advantage plans, members will have a coverage gap for prescriptions due to the donut hole.
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Can I still call the State Health Plan if I have questions about my insurance?
The State Health Plan can review benefit information with you. However, the State Health Plan would not be able to access the Humana or UnitedHealthcare systems to review any issues you may be experiencing. The State Health Plan would need to transfer you to your plan's Group Medicare Call Center or you could contact the Medicare Advantage plan directly.
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I am already a member of a Medicare Advantage plan. Can I keep this plan and enroll into one of the Group Medicare Advantage Plans being offered by the State Health Plan?
Federal regulations do not permit you to be enrolled in a Group Medicare Advantage plan at the same time you are enrolled in another Medicare Advantage plan or another Medicare Prescription Drug Plan (Medicare Part D). When you are enrolled in a Group Medicare Advantage plan, your other plan will be terminated December 31, 2013.
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Will the Group Medicare Advantage Plans coordinate with my Medigap (Medicare Supplement) policy?
Medigap (Medicare Supplement) policies will only coordinate with Original Medicare. They do not work with Medicare Advantage plans.
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Do I have to pay the Income-Related Monthly Adjusted Amount (IRMAA) if I join one of the Humana or UnitedHealthcare Group Medicare Advantage plans?
If you have a higher income level and are currently required to pay a higher Medicare Part B premium, then you will most likely have to pay IRMAA when enrolled in one of the State Health Plan sponsored Group Medicare Advantage plans. These Group Medicare Advantage plans include Medicare Part D prescription coverage and IRMAA is also applied to those with a higher income level for Medicare Part D coverage. The Social Security Administration is the responsible federal agency for determining and collecting any IRMAA amounts. Additional questions about IRMAA can be answered by Social Security Administration by calling 1-800-772-1213.
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Does the Medicare Advantage plan cover both my medical and pharmacy benefits?
Yes, all of the Group Medicare Advantage plans being offered cover both medical and pharmacy benefits. You do not need to purchase a separate Medicare Part D plan. In addition, these plans cover prescription drugs in the gap, otherwise referred to as the "donut hole." Plus, the plans include a maximum drug out-of-pocket amount of $2,500.
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Will I be required to pay a deductible and coinsurance with the Medicare Advantage Prescription Drug Plan?
No. There are no deductibles with these plans. In most cases, you will be required to pay a cost-share, whether it is a copayment or coinsurance.
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What are the premium rates?
Each carrier will provide a Medicare Advantage Base plan which will be premium-free for the retiree. They will also each provide an Enhanced plan which will have a monthly premium of $33 for the retiree. The rates for Medicare primary dependents are lower than under the Traditional 70/30 plan.
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I only have Part A. Can I enroll in the Medicare Advantage plan?
No. You must have Medicare Part A and Part B to be enrolled. To enroll in Medicare Part B, you will need to contact your local Social Security office to enroll or go to www.ssa.gov or call 1-800-772-1213 for enrollment information.
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How to I determine if my specific medications are covered under each plan?
Each carrier will be able to answer that question depending on their CMS approved formularies.
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What is the difference between Medicare Parts A & B (Original Medicare) vs. Medicare Part C (Medicare Advantage Plans) and Medicare Part D?
Medicare Part A & B:
  • Covers hospital stays, doctor and outpatient visits.
  • Offered by Government
Medicare Part C:
  • Combines Parts A and B
  • Offers additional benefits
  • Plans typically include Medicare prescription drug coverage (Part D)
  • Offered by private companies
Medicare Part D:
  • Covers prescription drugs only
  • Offered by private companies
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