Frequently Asked Questions

.
.
  • Medicare is a federal health insurance program aimed at people over 65, certain disabled people under 65 and people with End Stage Renal Disease. Original Medicare (pay per service) was established in 1965. When the Balanced Budget Act (BBA) of 1997 was enacted by Congress, many changes were put to action at Medicare as well as the manner in which the Centers for Medicare and Medicaid Services (CMS) administered the Medicare benefits. One of the results of the legislation was the creation of the Medicare Advantage program.

  • Medicare Part A covers hospital services such as those received by the patient at the hospital, care centers and certain types of specialized home care. 

  • Part B covers outpatient medical services and other services not covered by Medicare Part A. Part B is optional. These services include primary care provider visits and some preventive services such as routine tests, vaccines, among others.

  • It is a private plan that administers and manages Parts A and B of Medicare. This plan, also known as Medicare Advantage, is available for members with Parts A and B. Private Plans offer additional benefits and in many cases, Part D option. A Medicare Advantage plan may offer:

    • Access to physicians and specialists
    • Deductibles and coinsurance covers for Medicare Parts A and B
    • Hearing, vision and dental services coverage
    • Emergency and urgency coverage anywhere in the world
    • Routine service coverage in the U.S
  • It is a prescription drug coverage which offers Medicare beneficiaries a cost effective alternative to buy their drugs through a private plan. This coverage is optional and is only offered by private plans. If the beneficiary does not enroll when they are eligible for the first time and enroll later, they may have to pay a penalty. 

  • For Medicare Advantage plans with Part D prescription drug coverage, Medicare sets a limit on the total spending of drugs they cover during the year.  This figure includes the amount paid by the beneficiary, as well as the amount paid by the plan. After this amount is reached, the beneficiary reaches what is called a coverage gap stage.

     

    Since then, the beneficiary will receive limited coverage and/or discounts in certain drugs, and must pay for the remaining him/herself.  When the beneficiary reaches the new top amount for that stage, he/she then enters the next stage known as catastrophic coverage.  From that moment on, the plan will pay for most of the costs of their prescription drugs.

     

    For more detailed information on payment stages, please refer to your Evidence of Coverage (EOC).

  • October 15 – December 7  

    A member may make changes to his/her Medicare coverage, including Medicare Advantage plans and Medicare prescription drug coverage. This time of the year is known as the Annual Enrollment Period.

    January 1 – February 14

    A beneficiary can cancel his/her Medicare Advantage enrollment and switch to Original Medicare. If the beneficiary chooses to switch to Original Medicare, he/she may also choose a separate Medicare prescription drug plan at the same time. During this period (known as the Medicare Advantage Disenrollment Period), you can no longer switch to another Medicare Advantage plan.

    Special Enrollment Period

    A set time when members can change their health or drugs plans or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment Period include: if you move outside the service area, if you are getting “Extra Help” with your prescription drug costs, if you move into a nursing home, or if we violate our contract with you.