GENERAL – FREQUENTLY ASKED QUESTIONS

Use the search bar, or scroll through and click on a question below to see the answer and more information on the topic. you can also give us a call at 877-267-3752 and we will do the work for you!

I don’t wear glasses and can see fine! Why do I need an eye exam?

Getting an eye exam is not just about finding out if you need glasses. It’s about your health! An eye exam can detect eye health problems like glaucoma or cataracts, but it can also help identify early signs of diseases that impact your whole body- high blood pressure, diabetes and high cholesterol – just to name a few. So, schedule an exam today and keep an eye on your health.

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How do I report disability fraud?

If you suspect any sort of disability fraud, you can report it to the Social Security Administration (SSA) via Internet, phone, or mail. According to the Centers for Medicare & Medicaid Services, fraud is any act of intentional deception in order to receive an unlawful benefit. Examples of disability fraud may include making false statements on claims or concealing employment in order to continue receiving disability benefits.

If you are reporting disability fraud, you have the option to remain anonymous during the reporting process. However, keep in mind that this may limit the Social Security Administration’s ability to investigate your allegations, since the office will not be able to follow up with you for additional information.

To report fraud, waste, or abuse online, fill out this form on the Social Security website.

To report it via mail, send your report to:

Social Security Fraud Hotline

P.O. Box 17785

Baltimore, MD 21235

To report via telephone, call the Fraud Hotline at 1-800-269-0271 (TTY users 1-866-501-2101) from 10AM to 4PM Eastern Time. If you cannot reach a representative during this time, you may also report disability fraud through the Social Security toll-free number, and your information will be sent to the Fraud Hotline. Call Social Security at 1-800-772-1213 (TTY users 1-800-325-0778), Monday through Friday, from 7AM to 7PM.

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Why does my doctor no longer accept Medicare? What happens if my doctor leaves my Medicare Advantage plan network?

A doctor or provider may decide to “opt out” of Medicare for various reasons; for example, a practice may feel the need to reduce overhead costs or wish to keep the number of patients down in order to maintain a suitable level of care.

If your doctor opts out of Medicare, this means that he or she is no longer enrolled in the Medicare program and does not submit any claims to the federal program or Medicare health plans. The doctor becomes exempt from Medicare-approved spending limits, and you become responsible for paying the complete cost of your health care if you stay with that doctor.

Your costs are generally lowest if you get your services from a Medicare-participating doctor or provider. Participating providers agree to “accept assignment” for all Medicare-covered services, meaning that they will not charge you above the Medicare-approved amounts for a service. You’ll still be responsible for any cost sharing that may apply, such as copayments, coinsurance, or deductibles.

There may be other situations where your doctor remains in the Medicare program, but can choose on a case-by-case basis whether or not to accept Medicare assignment. This is known as a non-participating provider. If a doctor does not accept Medicare assignment for a given service, it means he or she does not accept the Medicare-approved cost amount and can charge you up to 15% more for their services. This is known as a “limiting charge.”

Original Medicare (Part A and Part B)

If you’re enrolled in Original Medicare and your doctor opts out of the Medicare program, you can find doctors who accept Medicare through Medicare.gov’s Physician Compare website. This site is a national database of physicians, specialists, and other health-care professionals who are enrolled in the Medicare program. The site includes both participating and non-participating providers, but you can choose to filter your search to only display doctors that accept assignment.

Using the site is hassle-free and easy. The Physician Compare tool lets you search for doctors and providers by:

  • Location and zip code
  • Area of practice (for example, cardiology)
  • Gender
  • Hospital affiliation
  • Your doctor’s last name

After entering in your search criteria, the Physician Compare page will display a list of doctors in your area that meet your requirements. Before settling on a doctor, you should first call to confirm that he or she accepts Medicare assignment and is taking new patients.

Medicare Advantage plans (Part C)

If you are enrolled in a Medicare Advantage plan (such as an HMO or PPO), your plan can make changes to its provider network anytime throughout the year. Your doctor and providers may also join or leave your plan’s network at any time. If your doctor leaves your Medicare Advantage plan’s provider network and you’d like to continue seeing him or her, you have a few options.

  • Switch plans during the Annual Election Period: If your doctor is part of another Medicare Advantage plan’s provider network, you can switch plans during the next Annual Election Period (October 15 to December 7).
  • Disenroll from your Medicare Advantage plan: If your doctor is no longer in the provider network for any Medicare Advantage plan (but is still accepting Medicare), you may decide to go back to Original Medicare in order to continue seeing him or her. You can use the Annual Election Period to disenroll from your Medicare Advantage plan and return to Original Medicare. Or you can also disenroll from your plan during the Medicare Advantage Disenrollment Period (January 1 to February 14); you can also use this disenrollment period to enroll in a stand-alone Medicare Prescription Drug plan.
  • Switch plans during a Special Election Period: In some situations, the Centers for Medicare & Medicaid Services (CMS) may decide that the change in provider network was significant enough to warrant a Special Election Period. Your Medicare Advantage plan will notify you if your situation qualifies, and you’ll then be able to use your Special Election Period to either enroll in another Medicare Advantage plan or return to Original Medicare.

There may be certain circumstances where your Medicare Advantage plan leaves the Medicare program entirely or makes changes in its contract with CMS that affect you. When this happens, you may be eligible for a Special Election Period (SEP) that lets you make changes to your coverage.

Times when you may be eligible for a Special Election Period may include, but are not limited to:

  • Your Medicare Advantage plan does not renew its plan contract or reduces its service area for the upcoming plan year.
  • Your Medicare Advantage plan substantially changes its contract with CMS.
  • Your Medicare Advantage plan violates its contract with CMS.
  • CMS terminates your Medicare Advantage plan’s contract as a result of misconduct or other problems.

During a Special Election Period, you can enroll in another Medicare Advantage plan or return to Original Medicare. The rules about what you can do may vary depending on the situation that prompted the Special Election Period in the first place.

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When does coverage begin?

Coverage becomes effective next day (12:01 am) following the date the completed enrollment form is received and approved, or a specified date in the future (not more than 30 days in advance), provided that full premium for the coverage has been received.

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Can I get a Medicare plan that covers a health club membership?

Original Medicare, Part A and Part B, does not cover any of the costs associated with gym memberships or fitness programs. However, there are other Medicare plan options that may cover the cost of a gym membership.

Medicare Advantage plans must offer at least the same amount of coverage as Original Medicare (besides hospice care, but that’s still covered under Medicare Part A), and may also offer additional benefits. These extra benefits could include gym membership. If you sign up for a Medicare Advantage plan, you’re still in the Medicare program and need to continue paying your Medicare Part B premium, as well as any premium the Medicare Advantage plan may charge.

On the other hand, Medicare Supplemental plans do not typically include fitness membership.

Because these Medicare plan options are offered through private, Medicare-approved insurance companies, their availability and benefits may differ by location. You may want to compare plans to see if one in your area offers coverage for health club membership costs.

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At what age should my child first visit the eye doctor?

The American Optometric Association recommends that your child should have his or her first eye exam with an optometrist or ophthalmologist between 6 months of age and 1 year. The doctor will check for nearsightedness, farsightedness, astigmatism, amblyopia (or “lazy eye”), proper eye movement and eye alignment, how the eye reacts to light and darkness, and other eye health problems.They also recommend that your child’s next eye exam should take place sometime between the ages of 3 and 5, and then every year after that. During these exams, the doctor will conduct a comprehensive eye exam as well as vision screening tests.

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Do I need to renew my Medicare coverage?

In general, once you’re enrolled in Medicare, you don’t need to take action to renew your coverage every year. This is true whether you are in Original Medicare, a Medicare Advantage plan, or a Medicare prescription drug plan. As long as you continue to pay any necessary premiums, your Medicare coverage should automatically renew every year with a few exceptions as described below.

There are some exceptions where you’ll need to take action to continue your coverage. Some situations where your Medicare Advantage or stand-alone Medicare Part D prescription drug plan coverage won’t be automatically renewed include, but aren’t limited to:

  • Your plan reduces its service area, and you now live outside of its coverage area.
  • Your plan doesn’t renew its Medicare contract for the upcoming year.
  • Your plan leaves the Medicare program in the middle of the year.
  • Medicare terminates its contract with your plan.

If your Medicare plan doesn’t renew its contract with Medicare for the coming year, your Special Election Period will run from December 8 to the last day of February of the following year. If you have Medicare Advantage and don’t enroll in a new plan by the date that your current plan ends its contract with Medicare, you’ll be automatically returned to Original Medicare.

Keep in mind that your new coverage starts on the first day of the month after you submit your enrollment application, meaning if you apply on February 8, your new Medicare plan wouldn’t begin until March 1.

You’ll also get a three-month Special Election Period if your Medicare Advantage or Medicare Part DPrescription Drug Plan terminates its contract with Medicare. This period starts two months before the contract ends and runs an additional month after the contract ends. If Medicare terminates your plan’s contract, you will have a Special Election Period that begins 1 month before the termination effective date and ends 2 months after the effective date of the termination.

While you may not need to renew your Medicare coverage, it’s still a good idea to review your coverage annually. Benefits, provider and pharmacy networks, drug formularies, and cost sharing can all change from year to year and affect how much you pay out of pocket. Comparing plans annually is one way to make sure your coverage continues to meet your health needs and budget.

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What is the difference between Medicare Supplement Plans F, G, and N?

Medicare Supplement (or Medigap) plans are standardized across the nation, except in Massachusetts, Minnesota, and Wisconsin. Each of the 10 plans is denoted by a letter, and the currently available plans are A, B, C, D, F, G, K, L, M, and N. These plans are provided through private insurance companies, but plan type with the same letter must offer the same set of basic benefits regardless of location.

Medigap Plan F is considered one of the most popular plans because it offers the most comprehensive coverage of certain health care costs, including:

  • Medicare Part A coinsurance and hospice care coinsurance
  • Medicare Part A deductible
  • Medicare Part B coinsurance or copayment
  • Medicare Part B deductible
  • Part B excess charges
  • First three pints of blood used in a procedure
  • Skilled nursing facility (SNF) care coinsurance
  • Coverage outside of the United States (up to plan limits)

Medigap Plan G offers all of the same benefits as Plan F except for the Part B deductible.

Medigap Plan N covers the same benefits as Plan F except the Part B deductible and Part B excess charges. Also, it covers the Medicare Part A deductible at 50% versus 100%. Medigap Plan N pays for 100% of the Part B coinsurance, except for copayments of up to $20 for certain office visits and up to a $50 for emergency room visits that do not result in an inpatient admission.

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When does coverage end?

An insured Member’s coverage ends when the Member is no longer eligible (as defined above), premiums are discontinued (subject to the grace period), when the policy terminates, or when the Member is no longer in good standing with the association, whichever occurs first. Coverage on a dependent ends on the earliest date they no longer meet the definition of an eligible dependent or on the date the Primary Member’s coverage terminates, whichever occurs first.

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What is SilverSneakers™? Does Medicare cover this program?

SilverSneakers is a program encouraging older adults to participate in physical activities that will help them to maintain greater control of their health. It sponsors activities and social events designed to keep seniors healthy while encouraging social interaction.

The program is available around the country, and membership provides access to any participating gym location–including all amenities included with basic level access. Each location is outfitted with an advisor who will introduce you to the program and help get you started. Access to HealthwaysFIT.com is also included as a way for you to track your progress, and SilverSneakers includes an invitation to sponsored health education seminars and other fitness-related events.

Medicare Advantage plans may cover SilverSneakers

SilverSneakers is considered a basic fitness service and Original Medicare, Part A and Part B, does not cover this benefit. However, Medicare Advantage plans, also known as Medicare Part C, may provide this benefit. To see if your current Medicare Advantage plan includes the SilverSneakers program, contact your health plan directly, or visit the SilverSneakers online health plan finder to check.

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My child gets a vision screening at school, so there is no need for an eye exam, right?

A vision screening does not take the place of an eye exam. They generally check a child’s ability to see far away and check for color blindness, but a comprehensive eye exam will evaluate the entire structure of the eye and also allow the doctor to view nerves and blood vessels, providing a glimpse into a child’s overall health. Eye doctors will also check for farsightedness, which is more common in younger children.

 

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How do I get a new Medicare card if my card is damaged, lost, or stolen?

If your Medicare card is lost, stolen or damaged, you can request a replacement Medicare card through the Social Security Administration in the following ways:

  • Online at www.ssa.gov.
  • By phone at 1-800-772-1213 (TTY users, dial 1-800-325-0778), Monday through Friday, from 7AM to 7PM.
  • In person at your local Social Security office.

Your new red, white, and blue card will be mailed to the address that Social Security has on file for you within 30 days.

If you have moved and have not reported this information to Social Security, you will need to report your address change before they can process your request for a replacement card.

If you need proof that you have Medicare sooner than 30 days, you also can request a letter to use as temporary proof. This letter should be mailed to you in about 10 days. If you need proof immediately for your doctor or for a prescription, visit your nearest Social Security office.

If you signed up for Medicare through the Railroad Retirement Board (RRB), you’ll need to request a replacement Medicare card through the RRB:

  • Visit www.rrb.gov.
  • Call 1-877-772-5772 (TTY users, dial 1-312-751-4701, Monday through Friday, from 9AM to 3:30PM.
  • Contact your local Railroad Retirement Board office.

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Why do I need to go through underwriting to get a Medicare Supplement plan?

Medical underwriting involves a review of your medical history. Some health insurers use underwriting to determine whether they will provide coverage to a prospective beneficiary, what premium to charge, and whether to impose a waiting period before coverage starts.

If you’re enrolled in Medicare, and you decide to add a Medicare Supplement (also known as Medigap or MedSup) plan to your Original Medicare coverage, the private insurance company might require underwriting before selling you a Medigap policy.

You can avoid underwriting, and enroll in any Medigap plan that’s available where you live, if you sign up for the Medigap plan during your six-month Medigap Open Enrollment Period. This period begins on the first day of the month that you’re both 65 years old and enrolled in Medicare Part B. For example, if you turn 65 on July 14, and are enrolled in Medicare Part B, you have until December 31 to enroll in a Medigap plan. If you apply for a Medigap plan during your Medigap Open Enrollment Period, your acceptance into the plan is guaranteed, and the plan can’t charge more if you have a health condition. As a prerequisite, you must be enrolled in Original Medicare, Part A and Part B.

If you apply for Medigap coverage after your open enrollment period has passed, you may have to go through medical underwriting. The insurer may review your medical history and refuse to sell you a policy, or sell you one at a higher cost, if you do not meet its underwriting requirements.

Sometimes you can join a Medigap plan after the Medigap Open Enrollment Period without undergoing a medical underwriting review. For example, if you’re enrolled in a Medicare Advantage plan and the plan leaves the Medicare program, you might have a “guaranteed-issue right” to a Medigap plan.

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What happens if I apply for this insurance and then change my mind and decide that this policy does not fit my needs?

You have the right to review your policy within 10 days from the date you have applied. After you apply, you will automatically receive an email for you to review your application and certificate. If you do wish to terminate the coverage after you have reviewed the certificate, you will need to contact the customer service department by phone. We also require a written request with the policy holder’s signature. If you have provided the correct information within the 10 day time frame, a refund of premiums, minus the administration fees will be issued and your policy will be deemed void, as though it had never been issued.

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What’s the difference between home health care and nursing home care?

Medicare considers home health care to be skilled, in-home nursing care or outpatient therapy services to treat an illness or injury. Nursing home care services are somewhat similar, but delivered in a skilled nursing facility (SNF). Whether Medicare covers these services will depend on the type of nursing care you need and how long you need it.

Medicare home health care

Intermittent or short-term home health services (for example, if you’re recovering after a recent hospitalization) are covered under Medicare Part A and Part B. These services must be provided by a Medicare-certified home health agency that works with your doctor to manage your care.

To be eligible for Medicare coverage:

  • Your doctor must order it medically necessary that you receive intermittent skilled nursing care or outpatient therapy services at home. Medicare defines “intermittent” care as care given less than seven days a week or less than eight hours a day, for no longer than 21 days. If you need more than intermittent nursing care, Medicare will generally not cover it except in special circumstances.
  • Your doctor must determine that your condition will improve, and that your need for home health services is temporary.
  • You must be homebound, meaning you can’t leave your home without assistance, or it might be dangerous to leave due to your health condition. Homebound doesn’t necessary mean bed-bound. You’re still considered homebound if you leave your home occasionally, for short periods of time, even for non-medical purposes like attending religious services.

Medicare covers your home health services over a 60-day period, after which the doctor must review your plan of care. However, there is no limit to the number of times your doctor can reorder this care for you, as long as it remains medically necessary to treat your condition.

Medicare-covered home health care may include:

  • Skilled nursing services given by a registered nurse or licensed practical nurse
  • Physical therapy, occupational therapy, or speech pathology services
  • Home health aide services
  • Medical social services
  • Durable medical equipment (DME)
  • Other supplies needed as part of your home care

Medicare coverage for in-home nursing care doesn’t usually include meals, homemaker services, or round-the-clock nursing. Custodial care isn’t covered if this is the only kind of care you need. Custodial care refers to personal assistance with daily living activities, such as bathing or getting dressed. These tasks are usually performed by home health aides and don’t require a medically trained nursing or rehabilitation team.

If you have Original Medicare, Part A and Part B, you pay nothing for the home health services and 20 percent of the Medicare-approved amount for any durable medical equipment (DME).

Medicare nursing home coverage

Medicare doesn’t generally pay for long-term nursing home care. Medicare Part A does cover medically necessary, short-term care in a skilled nursing facility under certain conditions. Part A covers a semi-private room, medical supplies used in the facility, meals, and other items; see What is Medicare Part A? for details.

To be eligible for nursing home coverage, Medicare requires you to meet criteria such as, but not limited to:

  • You have a qualifying inpatient hospital stay of at least three days before entering the SNF.
  • The SNF is Medicare-certified.
  • Your doctor orders this type of skilled daily care for you, indicating that it can only be delivered by a skilled nursing or rehabilitation staff (or under the staff’s supervision).
  • You’re enrolled in Medicare Part A, with days left in your benefit period.
  • You need treatment for a hospital-related medical condition, or for certain medical conditions you develop in the SNF.

If you live in a nursing home, Medicare still covers hospital and medical services under Part A and Part B. If you take medications, pharmacies contract with Medicare Part D Prescription Drug plans to provide drug coverage for nursing home residents.

Although Original Medicare generally doesn’t cover long-term nursing home care, you may be able to get help with costs if you have limited income and qualify for Medicaid. Contact your state Medicaid office to find out if you’re eligible.

In addition, some Medicare Advantage plans (offered by private Medicare-approved insurance companies) may include coverage for nursing home services. In most cases, long-term nursing home care is only covered if you live in a nursing home that is contracted with your plan. However, some Medicare Advantage plans have Special Needs Plans (SNPs) that may help you if you live in a nursing home or have certain conditions, such as congestive heart failure.

What kind of care do I need?

If you need short-term, skilled nursing care to recover from an illness or injury, Medicare Part A’s home health benefit might cover you. If you’re recovering from a hospital stay, Part A’s skilled nursing facility coverage might cover your needs. Your Medicare-assigned doctor can recommend the kind of care you need and help place you in the appropriate situation.

However, if you need full-time or long-term care, Original Medicare coverage may not be sufficient. eHealth’s plan comparison tool can help you find Medicare plan options that may offer nursing home coverage. To see which Medicare plan options are available in your area, simply enter your zip code into the form on this page. You can also compare plans at Medicare.gov or by calling 1-800-MEDICARE (1-800-633-4227) (TTY users 1-877-486-2048), 24 hours a day, seven days a week.

Many beneficiaries will need long-term care at some point in their lives, whether that takes place at home, in an assisted living facility, or in a nursing home. If you need such care, visit LongTermCare.gov for information on long-term care options.

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How often should I get an eye exam?

As with any type of ongoing health care, annual eye exams are a good rule of thumb unless otherwise directed by your doctor.

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What is my Medicare effective date?

For Original Medicare, Part A and Part B a simple way to determine your exact Medicare effective date is to refer to the lower right corner of your Medicare card or to refer to your letter from either the Social Security Administration or the Railroad Retirement Board.

If you have any questions about when your Medicare coverage starts, you can contact Social Security at 1-800-772-1213, Monday through Friday, from 7AM to 7PM. For TTY services, call 1-800-325-0778.

If you worked for a railroad, you can call the Railroad Retirement Board at 1-877-772-5772, Monday through Friday, from 9AM to 3:30PM. For TTY services, call 1-800-325-0778.

If you enroll into a Medicare Advantage or Medicare Prescription Drug Plan, the date your coverage starts can vary, depending on when you enroll and which election period you qualify for. For questions about your effective date on these types of Medicare plan options, you can contact the Medicare health or drug plan directly.

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Should I consider switching Medicare Supplement plans?

There can be good reasons to consider changing Medicare Supplement (Medigap) plans if you can find another insurer that’s willing to sell you a policy. Unlike other types of Medicare coverage, you can join or switch Medigap plans any time the plan is taking new members and will accept your enrollment.

However, you’ll usually have fewer options available if you switch plans after your Medigap Open Enrollment Period, the six-month period when you’re first eligible for Medicare Supplement insurance. During your Open Enrollment Period, you can join any plan with guaranteed issue, meaning Medigap insurers must sell you a policy and can’t charge you a higher premium for health reasons. After this period, you may have trouble finding an insurer that will sell you a plan, especially if you have pre-existing conditions.

If you do decide to switch plans, know that your Medigap coverage may cost more, and the plan may require medical underwriting. Also, keep in mind that if you switch Medigap plans and change your mind, you may not be able to get your old plan back.

Reasons to switch Medigap plans

That being said, there are certain situations where you might consider changing Medigap plans; you could even have guaranteed-issue rights in some circumstances. Some reasons include:

You’re unhappy with your Medigap insurance company. There are 10 Medigap plans available in most states, and coverage is standardized, meaning that plans of the same letter provide the same benefits, regardless of insurer. If you’re dissatisfied with your Medigap insurer and can find another insurance company that sells your current plan, you may want to switch plans and get the same benefits you currently have.

Your health needs have changed. If you’re in good health, you may want to switch to a Medicare Supplement plan with more basic coverage, so that you’re not paying for benefits you’re not using. Or, conversely, your health may have declined recently, and you may want to switch to a Medigap plan with more comprehensive coverage.

Your financial situation has changed. If your finances have changed, you may want to switch to a plan with a less expensive premium, especially since benefits are standardized for the same plans. Keep in mind that Medigap plans use different methods for pricing plan premiums. Some base premiums on your current age, meaning the premium cost increases with your age. Other insurers base the premium on your age when you enroll, while others charge all plan members the same premium, no matter how old they are. Always ask the Medicare Supplement insurer which pricing method it uses so you know how much you’ll pay both now and in the future.

You have a Medicare SELECT plan and moved out of the plan’s service area. Medicare SELECT plans are a type of Medigap plan that may require you to use certain provider networks to be covered. If you move out of your Medicare SELECT plan’s coverage area, you can switch to a Medigap Plan A, B, C, F, K, or L sold by any company in your new location that is licensed to sell the Medigap policy, no later than 63 calendar days after your coverage ends.

Your Medigap insurance company goes out of business. If you lose your Medigap plan because the insurer goes bankrupt, you have a guaranteed-issue right to join another Medicare Supplement plan. You can join a Medigap Plan A, B, C, F, K, or L sold by any company in your state that is licensed to sell the Medigap policy, no later than 63 calendar days after your coverage ends.

Your Medigap insurance company committed fraud. If your Medicare Supplement insurer misled you, you have a guaranteed-issue right to change Medigap plans. You can switch to a Medigap Plan A, B, C, F, K, or L sold by any company in your state that is licensed to sell the Medigap policy, no later than 63 calendar days after your coverage ends.

There are other situations when you may have guaranteed issue rights; check with Medicare (contact information below) or your health insurance plan.

If you’re thinking of changing Medicare Supplement plans, you can wait to drop your first policy while you decide which plan to keep. You have a right to try out your new Medigap policy for 30 days before dropping your original plan–or going back to your first policy if you’re not satisfied. This is known as your free-look period. You must pay both plan premiums for that month and state in your Medigap application that you’ll cancel the first Medigap plan after 30 days. After the first month, you can drop the Medigap plan you don’t want.

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Is Same-Sex Marriage, Domestic Partnerships, or Civil Unions allowed with these plans?

Yes and no; each state has enacted laws that determine eligibility under the plan. Call our toll free number to find out what is available in your particular state.

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Does Original Medicare cover funeral costs?

Original Medicare doesn’t cover funeral or burial costs in the event of a beneficiary’s death. This also applies if the beneficiary was enrolled in a Medicare Medical Savings Account plan, a type of a high-deductible Medicare Advantage plan that includes a savings account used to pay for medical expenses. Funeral or bereavement expenses aren’t considered medical expenses and can’t be paid for using funds from a Medical Savings Account plan.

While Medicare coverage is limited, the Social Security Administration does pay survivor benefits, which you can use to pay for funeral costs. This death benefit is a one-time payment to the spouse or child of the beneficiary. Eligibility and the benefit amount will depend on how long your loved one worked and paid Social Security taxes.

Reporting a Medicare beneficiary’s death

If your family member or loved one was a Medicare beneficiary, you’ll need to report the death to Medicare. You can do so by contacting Social Security at 1-800-772-1213, Monday through Friday, from 7AM to 7PM. TTY users can call 1-800-325-0778.

If your loved one worked for a railroad, contact the Railroad Retirement Board to report the death at 1-877-772-5772, Monday through Friday, from 9Am to 3:30PM. TTY users can call 1-312-751-4701.

If your loved one was enrolled in a Medicare plan from a Medicare-approved private insurer, such as a Medicare Advantage or Medicare Prescription Drug Plan, the Centers for Medicare & Medicaid Services will notify the plan after you report the death to Medicare. The beneficiary will be disenrolled from the plan the first day of the month after the month of death.

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How long does an eye exam typically take?

The time can vary, but it will usually take between 30 minutes and one hour. If your eyesight requires multiple tests or if you have a more complex problem, the exam may run longer or require subsequent visits. Plan for an hour to be on the safe side.

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If I retire at age 62, will I be eligible for Medicare at that time?

No, but in some cases, when one spouse turns 62, the other spouse may qualify for premium-free Medicare Part A even if he or she hasn’t worked.

Medicare benefits start once you reach the age of 65 (unless you qualify by disability). You’re automatically enrolled at age 65 if you’re already receiving Social Security or Railroad Retirement Board benefits.

If you’ve worked at least 10 years (40 quarters) while paying Medicare taxes, there is no monthly premium for your Medicare Part A (hospital insurance) benefits. But if you haven’t worked, or worked less than 10 years, you may qualify for premium-free Part A when your spouse turns 62, if she or he has worked at least 10 years while paying Medicare taxes. However, to be eligible for Medicare, you need to be 65 years old. You also need to be an American citizen or legal permanent resident of at least five continuous years.

So, to summarize with an example:

  • Bob is 65 years old. He’s on Medicare, but he pays a monthly premium for his Medicare Part A benefits. He only worked for seven years and no longer works.
  • His wife, Mary, has worked for over 30 years.
  • Mary turns 62. Now, Bob no longer has to pay a Medicare Part A monthly premium.
  • Mary still has to wait until age 65 to be eligible for Medicare (unless she qualifies by disability).

If you retire at age 62, you may be able to continue to get medical insurance coverage through your employer, or you can purchase coverage from a private insurance company until you turn 65. While waiting for Medicare enrollment eligibility, you may contact your State Health Insurance Assistance Program to discuss your options.

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What are the Medicare plan star ratings and how are they measured?

The Centers for Medicare & Medicaid Services (CMS) created a Star Rating system to help beneficiaries and their families compare plan performance and quality for Medicare Advantage plans, Medicare Prescription Drug Plans, and Medicare Cost plans.

Medicare plans are rated on a scale of 1 to 5, with a 5-star rating being the highest score a plan can receive. More stars indicate better performance and quality:

  • 5-star rating: Excellent
  • 4-star rating: Above Average
  • 3-star rating: Average
  • 2-star rating: Below Average
  • 1-star rating: Poor

For Medicare plans providing health coverage, such as Medicare Advantage or Medicare Cost plans, each plan is given an overall summary rating based on how it performs across five main categories:

  • Staying healthy: Plans are rated on whether members had access to preventive services to keep them healthy. This includes physical examinations, vaccinations like flu shots, and preventive screenings.
  • Chronic conditions management: Plans are rated for care coordination and how frequently members received services for long-term health conditions.
  • Member experience: Plans are rated for overall satisfaction with the health plan.
  • Member complaints: Plans are rated on how frequently members submitted complaints or left the plan, whether members had issues getting needed services, and whether plan performance improved from one year to the next.
  • Customer service: Plans are rated for quality of call center services (including TTY and interpreter services) and processing appeals and new enrollments in a timely manner.

For Medicare Part D stand-alone Prescription Drug Plans and Medicare Advantage plans that include drug coverage, Medicare star ratings are also based on the following criteria:

  • Member experience
  • Member complaints
  • Customer service
  • Drug safety and drug pricing accuracy

The drug safety score is based on factors such as how accurate the plan’s pricing information is and how often members with certain medical conditions are prescribed drugs in a way that is safer and clinically recommended for their condition. Plans are also rated for whether drug pricing information on Medicare Part D Prescription Drug Plan and Medicare Advantage Prescription Drug plan websites is up-to-date and accurate. In addition, the percentage of plan members who got prescriptions for certain drugs with a high risk of serious side effects when there may have been a safer drug choice is also reviewed and scored.

The overall rating gives a quick summary of a plan’s performance, but you can also look up how the plan scored for individual areas within the above main categories. For more information on the criteria Medicare considers when rating its plans, visit Medicare.gov.

Keep in mind that plan ratings can change from year to year and are updated every fall. If you are enrolled in a Medicare plan, be sure to check the Medicare star ratings every fall so you can make an informed decision about whether to stay on the plan or switch to a different plan.

How to enroll in a Medicare 5-star rated plan

You can sign up for a 5-star rated Medicare Advantage, Medicare Prescription Drug Plan, or Medicare Cost Plan during the Annual Election Period.

If your Medicare plan doesn’t have a 5-star rating, you can switch to a Medicare 5-star rated plan within your service area one time during the 5-Star Special Election Period (SEP) from December 8 to November 30. If you have just switched Medicare Advantage plans during your AEP, this SEP is only available the following year.

If you decide to switch from your current Medicare Advantage plan to one with a 5-star rating, make sure you choose a plan that has prescription drug coverage, if you want this kind of coverage. Otherwise, you could pay a late-enrollment penalty if you add drug coverage at a later date.

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Do I have to use a vision PPO provider to receive benefits?

No. All members and their covered dependents have the freedom to choose any licensed vision provider. The PPO providers available to you have agreed to negotiated fees, so out-of-pocket costs for the member are often much lower than using a non-participating provider.

We highly recommend using a vision provider within the network to experience the best value and lowest out of pocket costs.

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Does Medicare cover overseas travel emergencies?

If you’re a Medicare beneficiary and like to travel, it’s a good idea to make sure you have health coverage in case of an emergency. While Original Medicare coverage may not be available outside the United States, some Medicare Supplement (Medigap) plans may include this coverage.

Original Medicare and travel coverage

For the most part, Original Medicare, Part A and Part B, doesn’t cover medical services or items you get outside the country. Medicare considers the United States to include the District of Columbia, Puerto Rico, the Northern Mariana Islands, Guam, American Samoa, and the U.S. Virgin Islands.

There are some exceptions:

  • If you live in the U.S. and the closest hospital that can treat your condition is outside the country, Medicare might cover care in that hospital, even when it’s not an emergency.
  • If you have a medical emergency while traveling between Alaska and another state by the most direct route possible and as fast as reasonably possible, Medicare might cover care in a Canadian hospital. The Canadian hospital would have to be closer to you than the closest U.S. hospital.
  • If you have a medical emergency in the U.S., but the closest hospital is outside the country, Medicare might cover care in the foreign hospital.
  • Dialysis may be covered in emergency situations outside the U.S., but not routine dialysis.
  • In some situations, Medicare may cover emergency medical treatment on a cruise ship. The ship must be no more than six hours from a U.S. port, and the doctor must be authorized by law to provide the treatment.

Medicare Part D (prescription drug coverage) doesn’t cover medications purchased outside the U.S.

Medigap plans and travel coverage

Medicare Supplement (Medigap) insurance is optional insurance you can get from a private insurance company. Medigap plans pay some of your Original Medicare (Part A and Part B) costs, such as coinsurance and copayments.

In 47 states, there are 10 standardized Medigap plans, each one named with a letter (such as Plan M). Every plan includes the same benefits as other plans of the same name, so that a Medigap Plan M offers the same coverage no matter where you buy it. Massachusetts, Minnesota, and Wisconsin have their own standardized Medigap policies.

Some Medigap plans cover emergency medical services you receive outside the United States. Medigap Plans C, D, F, G, M, and N pay 80% of your costs for certain emergency care in a foreign country if your situation meets all of the following conditions:

  • The care you receive is medically necessary.
  • The care begins during the first 60 days of your travel.
  • Medicare doesn’t otherwise cover this care.
  • You’ve met your Medigap deductible for the year.

If you still have a Medigap Plan E, H, I, or J, these plans also cover overseas medical emergencies, but these plans are no longer sold.

A Medigap plan with emergency medical coverage outside the U.S. has a lifetime maximum coverage limit of $50,000.

It’s a good idea to contact your Medigap insurance company to ask for details about travel coverage. You may also decide to purchase separate travel insurance.

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Why does the eye doctor perform so many tests?

Eye doctors perform various tests to examine all parts of the eye, as well as to gauge your overall health. Some procedures are designed to evaluate your vision, others allow the doctor to look at the structure of the eye, and still others help detect specific diseases. Visit www.EyeSiteOnWellness.com for additional information and videos about what to expect during an eye exam.

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Can I get a Medicare Supplement Plan if I am under 65?

Federal law does not require a company to sell Medicare Supplement plans (also known as Medigap or MedSup) to those under age 65, although some states require it. Because of this, Medigap insurers may choose to deny you a policy before you turn 65, or they may significantly reduce the number of available plans.

The following states require insurance companies to allow you to obtain at least one kind ofMedicare Supplement coverage before you reach age 65 (restrictions noted):

  • California (excluding those under 65 and with end-stage renal disease)
  • Colorado
  • Connecticut
  • Delaware (only available to those with end-stage renal disease)
  • Florida
  • Georgia
  • Hawaii
  • Illinois
  • Kansas
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts (only available to those with end-stage renal disease)
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • New Hampshire
  • New Jersey
  • New York
  • North Carolina
  • Oklahoma
  • Oregon
  • Pennsylvania
  • South Dakota
  • Tennessee
  • Texas
  • Vermont (excluding those under 65 and with end-stage renal disease)
  • Wisconsin

The best time to join a Medigap plan is during your Medigap Open Enrollment Period. This is the six-month period that begins on the first day of the month that you turn age 65 and are enrolled in Medicare Part B. During this time, you are entitled to join any Medigap plan that is available in your state, regardless of health issues.

Medical underwriting

Once this enrollment period passes, Medigap insurers may require you to have a medical underwriting examination, which is a thorough review of your medical history. Depending on your health issues, you could wind up paying a higher price for Medigap insurance or even be denied coverage completely.

The start date of your Medigap Open Enrollment Period cannot be delayed or replaced.

Guaranteed-issue rights

Guaranteed-issue rights are also known as Medigap protections. These guaranteed-issue rights refer to certain situations where insurance companies must offer you certain Medigap policies. You have a guaranteed-issue right to join a Medicare Supplement plan if you’re in a Medicare Advantage plan and you move out of the plan’s service area or if the company offering the policy is leaving Medicare or stops giving care in your area.

When this happens, you may have the right to buy certain types of Medigap (or Medicare Supplement) policies sold in your state if you switch to Original Medicare. The Medigap insurance company must cover all your pre-existing health conditions, and it cannot charge you higher rates for a Medigap policy because of existing health conditions

Please note that you may also have a “trial right” to try a Medicare Advantage plan (Part C), even if you have Original Medicare, Part A and Part B, and a Medigap policy. If you decide you do not like the Medicare Advantage plan, you may drop it without penalty and switch back to Original Medicare along with Medigap coverage, within a certain period of time.

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How can I find a provider participating in the network?

Provider directories can be accessed via the website, www.RealtorsInsuranceMarketplace.com. Members can search for a specific provider by name, or search for a provider by an address or zip code location. Provider directories are updated on a daily basis. The Provider Relations Department has a toll free number (800.755.8844) to verify participating providers and answer questions about participating providers.

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Medicare’s Alcohol-Dependency Counseling and Smoking Cessation Coverage

Medicare health insurance isn’t just for doctors’ services and inpatient hospital care. Beneficiaries can get help for alcohol- and tobacco-dependency issues whether they’re enrolled in Original Medicare, Part A and Part B, or a Medicare Advantage plan. Original Medicare is the federally funded health insurance program, while Medicare Advantage plans are offered by private Medicare-approved insurance companies.

These counseling/educational services are covered under Medicare Part B. This insurance covers doctors’ services, some preventive care, and durable medical equipment. Beneficiaries who chose to receive their benefits through a Medicare Advantage plan, also called Medicare Part C, will find that they are covered as well because these plans must provide at least the same amount of coverage as Original Medicare, Part A and Part B (with the exception of hospice care, which is still covered by Part A).

Alcohol-dependency counseling

The U.S. Surgeon General defines alcohol dependency as “a maladaptive pattern of drinking, leading to clinically significant impairments or distress.” These are some of the symptoms:

  • Needing to drink more and more alcohol to reach intoxication.
  • Drinking to avoid feelings of alcohol withdrawal.
  • Drinking more or over longer periods of time than you used to.
  • Trying unsuccessfully to drink less.
  • Giving up social activities in favor of drinking.
  • Spending more time obtaining, drinking, or recovering from drinking alcohol.
  • Continuing to drink despite knowing how it harms you.

Medicare beneficiaries who consume alcohol, but don’t meet the medical definition of alcohol dependency as defined above, are eligible for an annual screening. The screening can help your primary care doctor decide whether or not you have a problem with alcohol. If your doctor finds that you qualify, you can get four counseling sessions each year with your primary care physician or other eligible provider. Counseling must be done in a professional setting, such as a doctor’s office or hospital.

The alcohol-dependency screening and counseling sessions are free and not subject to your deductible, as long as the physician accepts Medicare assignment.

Smoking and tobacco cessation

Smoking and tobacco cessation means quitting smoking. According to the Centers for Disease Control and Prevention, cigarette smoking is responsible for over 480,000 deaths each year, and causes more deaths than HIV/AIDS, illegal drug use, alcohol use, motor vehicle fatalities, and firearms combined.

Medicare Part B covers up to eight face-to-face counseling sessions each year. The counseling sessions are no cost, provided that the doctor accepts Medicare assignment.

The Part B deductible amount and coinsurance could apply if you’ve been diagnosed with an illness or complication caused by tobacco use, such as:

  • Cardiovascular disease
  • Respiratory disease
  • Cancer (all types)
  • Teeth and gum health
  • Type 2 diabetes
  • Rheumatoid arthritis
  • Impaired immunity
  • Cataracts

If you have Medicare Advantage, costs may vary, as Medicare Advantage plans are run by private insurance companies.

 

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Can I get the same quality of care at a retail provider as I can at an independent doctor?

Absolutely. In fact, many of the optometrists who practice in retail settings share space with an optical store but operate separately. All optometrists, regardless of the setting of their practice, must meet the same state licensing and credentialing requirements. In addition, due to the finite number of optometry schools in the United States, optometrists are trained consistently regardless of the practice model they eventually choose.

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Will my spouse of 62 receive Medicare if I’m 65 and I receive Medicare benefits?

Unlike employer-sponsored group coverage, your spouse cannot get Medicare based on your Medicare eligibility if he or she does not otherwise qualify for Medicare coverage. Your spouse must qualify for Medicare by age or disability to receive Medicare coverage.

The minimum age for Medicare eligibility is 65 years old unless you qualify through disability or certain conditions. You must be either an American citizen or legal permanent resident of at least five continuous years. If your spouse is under 65 but has been receiving disability benefits from Social Security or the Railroad Retirement Board for 24 months, he or she will automatically qualify for Medicare in the 25th month of receiving disability benefits. Your spouse may also qualify for Medicare before 65 through end-stage renal disease or amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease).

If none of the above situations apply, your spouse may have to wait until age 65 to be eligible for Medicare.

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What does Medicare Part A cover?

Medicare Part A, also known as hospital insurance, is part of Original Medicare, which is federal Medicare health insurance for qualified Americans aged 65 and older or to those of any age who enter their 25th month of receiving disability benefits through Social Security or the Railroad Retirement Board. You may also qualify at any age if you have certain health conditions, such as end-stage renal disease or amyotrophic lateral sclerosis (or Lou Gehrig’s disease). To be eligible for Medicare, you must be a U.S. citizen or a legal permanent resident of at least five continuous years.

Medicare Part A generally covers medically necessary services and supplies needed to treat a certain disease or condition and care when you’re a hospital inpatient in a Medicare-enrolled hospital. The following list describes some of the main services and supplies Part A specifically covers (this is not necessarily a complete list).

  • Hospital care: If you’re admitted as an inpatient, Medicare covers semi-private rooms, prescription drugs given as part of your inpatient treatment, meals, general nursing, and more.
  • Long-term care hospitals: Medicare covers long-term care hospital services if you were transferred from an acute-care hospital or admitted to the long-term care hospital within 60 days of being discharged from an inpatient hospital stay.
  • Skilled nursing facility care: If your doctor determines that you need care in a Medicare-certified skilled nursing facility, Medicare Part A covers certain services and supplies, generally for a limited time.

Medicare may cover services and supplies including, but not limited to: semi-private rooms, meals, skilled nursing care, medications, medical supplies and equipment, and ambulance transportation. There are several qualifying factors that determine whether Medicare will cover your stay in such a facility.

  • Nursing home care: Medicare might cover care in a skilled nursing facility (described above) as long as you need skilled nursing care and not just custodial care (help with eating, dressing, bathing, etc.).
  • Hospice: Medicare covers doctor services, nursing care, medical equipment, medical supplies, and more. To qualify, your doctor must certify that you’re terminally ill and expected live six months or less; you must agree to accept palliative care (aimed at easing your pain instead of delivering a cure); and you must sign an agreement stating that you’re accepting hospice care instead of other Medicare-covered treatments for your health condition.
  • Home health services: Medicare may cover certain home health services, generally for a limited time while you recover from a hospital stay. Medicare may cover intermittent at-home skilled nursing care, physical therapy, occupational services, and more for beneficiaries whose doctors certify that they need this care at home. The home health agency caring for the beneficiary must be Medicare-certified.

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Do you require a pre-authorization for any claims?

No. Ameritas does not require pre-authorization. However, pretreatment estimates are available anytime a member would like to know how the plan will cover their services. This can be a valuable tool for Members to use in budgeted their out of pocket expenses. Information regarding pretreatment can be found on the backside of the Ameritas claim form or by calling Ameritas’ toll free Claim Customer Service lines. Once the pretreatment estimate is processed, a copy of the estimate is sent to the member and the vision provider.

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Where do I send my payment for the bill I received for my Medicare premiums?

If you’re currently receiving retirement benefits from the Social Security Administration, Railroad Retirement Board, or Civil Service, then your Medicare Part A (if you pay a premium for it) and/or Part B premiums will be automatically deducted from your benefit payments. If you aren’t currently receiving retirement benefits, you’ll get a “Notice of Medicare Premium Payment Due” bill in the mail to pay your premiums manually.

You have a couple options when it comes to paying your Medicare premiums.

Paying your premiums by mail

You can mail your Medicare premium payment in the pre-addressed envelope included with your billing notice. Be sure to fill out and include the bottom section of your premium bill when mailing back your payment.

You can send your Medicare premium payments by mail to the following address:

Medicare Premium Collection Center

P.O. Box 790355

St. Louis, MO 63179-0355

To ensure your account is credited properly, please write your Medicare number clearly on the check or money order. Or, if you are paying with a credit card or debit card, make sure to provide the account number and expiration date exactly as it appears on your card.

If you lose the pre-addressed envelope or have questions about where to send your payment, contact Medicare. You can reach Medicare by visiting Medicare.gov or calling 1-800-MEDICARE (1-800-633-4227) (TTY users 1-877-486-2048), available 24/7.

If you received a bill for your Medicare premiums from the Railroad Retirement Board (RRB), you should mail your payment to the RRB at:

RRB, Medicare Premium Payments

P.O. Box 979024

St. Louis, MO 63197-9000

Medicare Easy Pay

Alternatively, you can also sign up for Medicare Easy Pay, an electronic payment method that automatically deducts your premium payments from your bank account each month. To sign up for Medicare Easy Pay, visit Medicare.gov and fill out an authorization form to sign up. If you need help or have questions about Medicare Easy Pay, call 1-800-MEDICARE (1-800-633-4227) (TTY users 1-877-486-2048), available 24/7.

Online bill payments through your bank

Your bank may offer an online bill payment service that lets you pay for your Medicare premiums over the Internet. Contact your bank to find out if they provide this service. Keep in mind that some banks may charge a fee to process online payments, so check with your bank for more details.

Premiums for Medicare plans

If you are enrolled in a Medicare Prescription Drug Plan, Medicare Advantage plan, or Medicare Supplement plan, you may have a separate monthly premium for your Medicare plan. In these situations, you’ll send premiums payments directly to your Medicare plan, not the federal Medicare program, Medicare.gov, or the Railroad Retirement Board. Many Medicare plans give you the option to make premium payments online or by mail. If you have questions about billing or where to send the payment for your plan premium, contact your Medicare plan for more information.

If you have Medicare Part D, you’ll pay the premium for your Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan directly to your Medicare plan. However, in some situations, you may have to pay an extra amount if your income falls above a certain threshold; this extra cost is known as a Part D income-related monthly adjustment amount (Part D-IRMAA). Medicare will notify you if you need to pay the Part D-IRMAA. Important note: If you need to pay the Part D-IRMAA, you’ll pay this directly to Medicare, not your Medicare plan.

Like your Medicare Part A and/or Part B premiums, you can get your Part D-IRMAA bill automatically deducted from your Social Security, Railroad Retirement Board, or Civil Service benefit. Otherwise, you can pay for your Part D-IRMAA bill in the same ways that you pay for your Medicare Part A and/or Part B premiums: By mail through check, money order, credit card, or debit card; through Medicare Easy Pay; or through your bank’s online payment service.

Remember, regardless of the type of Medicare plan you’re enrolled in, you’ll need to continue to paying your Medicare Part B premium, in addition to any premium required by your Medicare plan.

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What are the different types of corrective lenses?

Corrective Lenses

Single Lenses

A single vision lens has just one power. It is focusing at one range. For a nearsighted person who cannot see far away, the lens is a “minus lens” which is thick on the edge, thin in the middle. For a person who is farsighted or has difficulty reading, the lens is a “plus lens” which is thick in the middle, thin on the edge.

Bifocal Lenses

Bifocal lenses are typically for the presbyopic patient who has a hard time seeing both distance and up close. This requires two different vision corrections in the glass. The near and distance pieces of the lenses are called “segments.” The top part of the lens is usually used for distance and the bottom part is used for up-close work.
A popular option is the no-line bifocal in which the line between segments is not visible. This creates a more youthful appearance, although there may be an additional cost for this option.

Trifocal Lenses

Trifocal lenses accommodate a person who has a visual need at three distances: far away, at an intermediate distance, and up close.

Lenticular Lenses

Lenticular lenses consist of an array of optical elements called lenticules. These lenses are designed to treat eye conditions that are more serious than simple myopia, hyperopia, presbyopia, or astigmatism. They are occasionally prescribed after cataract surgery for patients without intraocular implants; however, advances in surgical procedures have resulted in fewer prescriptions for Lenticular lenses.

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Will my spouse and dependent children also receive Medicare benefits?

Medicare is not offered as a family or dependent benefit. To get Medicare, each person must qualify on an individual basis in most situations and be either a U.S. citizen or a legal permanent resident of at least five continuous years.

For example, a person under age 65 does not automatically receive Medicare because his or her spouse is 65 or older and enrolled in the Medicare program. Also, when one or two parents qualify for Medicare, this does not mean their dependent children are covered by Medicare. For additional information on Medicare eligibility requirements, please view this article on Medicare eligibility.

However, if you’re the spouse or dependent child of someone who qualifies for Medicare because of end-stage renal disease (ESRD), you may be eligible for Medicare benefits.

If you or someone you know needs health insurance but does not qualify for Medicare, contact your State Health Insurance Assistance Program to discuss your options.

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What is prior authorization, step therapy, and quantity limit?

Prior authorization

Some Medicare Prescription Drug Plans may require prior authorization for Medicare coverage for certain medications. This means that before the Medicare Prescription Drug Plan will cover a particular drug, your doctor, or your prescriber must first show that you have a medically necessary need for that particular drug and/or have met the prior authorization requirements for the drug. Plans may require prior authorization to be sure that drugs are prescribed and used correctly.

Step therapy

Step therapy is a type of prior authorization. In most cases, you must first try a less expensive drug on the Medicare Prescription Drug Plan’s formulary (also called a drug list) that has been proven effective for most people with your condition before you can move up a “step” to a more expensive drug. This might mean trying a similar, more affordable generic drug instead of a more expensive,brand-name medication. The more affordable drugs in the first phase are known as “Step 1” prescription drugs. Please note that the formulary may change at any time. You will receive notice when necessary.

However, if you have already tried the more affordable drug and it didn’t work or if your prescriber believes that it is medically necessary for you to be on a more expensive drug, he or she can contact the plan to request an exception. If your prescriber’s request is approved, the plan will cover the more expensive drug. The more expensive drugs are known as “Step 2” prescription drugs, and Medicare will not cover them until Step 1 drugs are first tried unless an exception is obtained.

Quantity limit

For safety and cost reasons, plans may set quantity limits on the amount of drugs they cover over a certain period of time. For example, a person may be prescribed a medication to take two tablets per day, or 60 tablets per month. If the plan has a quantity limit of 30 tablets per month for that medication, your doctor or prescriber will need to work with the Medicare Prescription Drug Plan to get authorization for a higher quantity.

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How does the plan handle pre-existing conditions?

The plan does not limit pre-existing conditions.

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How can I set up payment methods for my Medicare premiums?

Most Medicare beneficiaries pay a monthly premium for Medicare Part B (medical insurance).

  • If you receive Social Security, Railroad Retirement Board (RRB), or civil service benefits, the premium is typically deducted from your benefit payment.
  • If you don’t receive the retirement payments listed above, you may be billed for the cost of your premium.

Some beneficiaries also pay a monthly premium for Medicare Part A (hospital insurance).

  • If you did not qualify for premium-free Medicare Part A, you have to pay a monthly premium. You qualify for premium-free Part A if you worked at least 10 years (40 quarters) while paying Medicare taxes.

You may pay for Medicare premiums in the following ways:

Online, through your bank

Contact your bank, or go to your bank’s website, to set up automatic payment. Here’s the payee information you’ll need:

  • Your Medicare account number — it’s on your red, white, and blue Medicare card. Don’t enter the dashes when you enter this number.
  • The payee name: CMS Medicare Insurance
  • The remittance address: Medicare Premium Collection Center, P.O. Box 790355, St. Louis, MO 63179-0355
  • The premium amount

Note: If your Medicare premium bill comes from the Railroad Retirement Board (RRB), or if you receive Civil Service benefits, see the information at the end of this article.

By credit or debit card

  • Refer to the bottom portion of your Medicare bill and complete the instructions for paying by credit or debit card.
  • You’ll need your credit or debit card handy so you can fill in the account number and other information.
  • Mail your payment to the address above, unless you receive your retirement benefits from the RRB or Civil Service; in these cases, see the information at the end of this article.

Through Medicare Easy Pay

  • Sign up for Medicare Easy Pay, which is a free, electronic payment option that automatically deducts premium payments from your savings or checking account each month it is due. To sign up, go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY users, call 1-877-486-2048). Representatives are available 24 hours a day, seven days a week.

By mail

  • Mail your check or money order to Medicare at Medicare Premium Collection Center, P.O. Box 790355, St. Louis, MO 63179-0355. Follow the instructions in your Medicare premium bill and mail your payment to the address listed in the form.

Note: If your Medicare premium bill comes from the Railroad Retirement Board, or if you receive Civil Service benefits, see the information at the end of this article.

If your Medicare bill comes from the RRB

The payee’s mailing address is: Railroad Retirement Board, Medicare Premium Payments, P.O. Box 979024, St. Louis, MO 63197-9000.

If you receive Civil Service retiree benefits

If you’re a Civil Service retiree and not eligible for Social Security benefits, do either of the following:

  • Contact the Center for Medicare & Medicaid Services (CMS) at the following email address:

OPMMailbox@cms.hhs.gov.

  • Call Medicare at 1-800-MEDICARE (1-800-633-4227; TTY users, call 1-877-486-2048). Representatives are available 24 hours a day, seven days a week.

 

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What types of bifocals are there?

No-line bifocals: contain a lens with two powers.

Progressive bifocals: gradually change from the top of the lens to the bottom.

 

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Will my non-working spouse, who turns 65 before me, get Medicare at age 65?

Americans who satisfy residency requirements are generally eligible for Original Medicare, Part A and Part B, at age 65, regardless of marital status. However, whether you have worked and paid Medicare taxes, and for how long, can affect whether you’re automatically enrolled in Medicare and whether you pay a premium for Medicare Part A. (To meet Medicare’s residency requirements, you need to be an American citizen or legal permanent resident of at least five continuous years.)

Generally, you don’t pay a monthly Medicare Part A premium if you’ve worked for 40 quarters (10 years) while paying Medicare taxes. You typically pay a monthly premium for Medicare Part B.

If you are at least age 62 and have worked for at least 10 years in Medicare-covered employment, your spouse can get Medicare, Part A premium-free when he or she is age 65 or older.

If you have worked at least 10 years in Medicare-covered employment but are not yet age 62 when your spouse turns age 65, he or she will not be eligible for premium-free Medicare Part A. In this case, your spouse can still enroll in Part A, but will have to pay a premium until you are age 62.

Some beneficiaries choose to delay enrollment in Medicare Part B, but if your spouse doesn’t enroll when first eligible for Medicare, he or she might pay a late-enrollment penalty. However, if you are still working and your spouse is covered under your group health plan, your spouse may be able to delay enrollment in Part B without a late-enrollment penalty. Check with your group health plan to see how it works with Medicare.

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Will Medicare pay for my durable medical equipment?

Durable medical equipment (DME) is reusable medical equipment, such as walkers, wheelchairs, or crutches. If you have Medicare Part B, Medicare covers certain medically necessary durable medical equipment if your physician or treating practitioner prescribes it for you to use in your home.

To be covered, the prescribed medical equipment must be:

  • Durable.
  • Used for a medical purpose.
  • Not typically useful if you aren’t sick or hurt.
  • Used in your home.*

*If you are currently residing in a hospital or nursing home that is providing you with Medicare-covered care, these facilities don’t qualify as your “home.” However, a long-term care facility does qualify as your home. If you’re staying in a skilled nursing facility and the facility provides you with durable medical equipment, the nursing facility is responsible for the durable medical equipment.

Some examples of durable medical equipment that Medicare covers may include, but isn’t limited to: Hospital beds, infusion supplies, oxygen equipment, patient lifts, and blood sugar monitors. If you have questions about whether a particular item or supply is covered, call 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. Medicare customer service representatives are available 24 hours a day, seven days a week.

For more information, see this article on Medicare coverage of durable medical equipment.

Where can I get durable medical equipment?

If you’re enrolled in Original Medicare, you need to get your durable medical equipment from a supplier that is enrolled in the Medicare program, or Medicare won’t pay for the equipment. For the lowest costs, find suppliers that are “participating,” meaning they accept the Medicare-approved cost for the equipment and will not charge you above that amount. To find Medicare-participating suppliers, visit the Medicare.gov Supplier Directory. If you live in an area that is part of Medicare’s Competitive Bidding Program, you’ll need to get equipment from suppliers that are contracted by Medicare. For more information on the Competitive Bidding Program and to find out if you live in a region that is affected, visit Medicare.gov.

Medicare Advantage plans (like HMOs or PPOs) must cover at least the same level of coverage as Original Medicare. However, costs may vary, depending on your Medicare Advantage plan. If you are in a Medicare Advantage plan and you need durable medical equipment, call your plan directly to find out if the equipment is covered and to see how much you will have to pay.

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How does the plan treat work in progress?

Any procedures started prior to the member’s effective date of coverage will not be eligible under the plan.

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What is MDLIVE?

With MDLIVE, you can access a doctor from your home, office, or on the go- 24/7/365. Our Board Certified doctors can visit with you either by phone or secure video to help treat any non-emergency medical conditions. Our doctors can diagnose your symptoms, prescribe medication, and send prescriptions to your pharmacy of choice.*

* Please note: Some state laws require that a doctor can only prescribe medication in certain situations and subject to certain limitations.

MDLIVE Prescription Policy

Doctors providing consultations for MDLIVE members offer prescriptions for a wide range of products that deliver direct medicinal value. These include, but are not limited to, drug classes such as antibiotics and antihistamines. Convenience prescriptions for maintenance medicines may also be obtained in cases where a member is in transition to a new insurance plan or doctor.

It is important to note that MDLIVE is not a drug fulfillment warehouse. In the event a doctor does prescribe medication, he/she will usually limit the supply to no more than thirty days. Patients with chronic illnesses should visit their primary care doctors or other specialists for extended care. MDLIVE doctors do not issue prescriptions for substances controlled by the DEA, for non-therapeutic use, and/or those which may be harmful (potential for abuse or addiction).

For a current list of DEA controlled substances, visit http://www.deadiversion.usdoj.gov/schedules/

 

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How do I submit a claim (bill) to Medicare?

You should not need to submit a Medicare claim or bill, but there may be rare circumstances that you may need to. Original Medicare, Part A and Part B, providers (including hospitals, skilled nursing facilities, home health agencies, physicians, pharmacies, and suppliers) that are enrolled in the Medicare program are required by law to file Medicare claims for covered services or supplies you receive. Medicare claims must be filed within one full calendar year following the year in which the services were provided.

If you receive a service or supply from a health-care provider who does not accept Medicare assignment, you might have to pay the entire charge at the time of service.

If a claim isn’t filed within the time limit, Medicare may not pay its share. It’s important to check your Medicare Summary Notice (MSN) to make sure your claims are being filed on time. If you discover claims are not being filed in a timely manner, you should first contact your physician and/or supplier and ask them to file the claim. If your claim is still not filed once you ask them to, call 1-800-Medicare (1-800-633-4227), TTY users 1-877-486-2048; 24 hours a day, 7 days a week. You can also file the claim yourself by submitting the Patient Request for Medicare Payment form (CMS-1490S).

Note: If you get your Medicare health-care benefits through a Medicare Advantage (MA) plan such as an HMO (Health Maintenance Organization) or a Private Fee-For-Service plan, then the claims are filed with the Medicare Advantage plan. Medicare pays these private insurance companies a set amount every month to administer and manage your benefits. Therefore, a separate claim does not need to be filed with Medicare.

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What are the types of lens options?

Lens Options

Glass:  Lenses that have great clarity and are more resistant to scratching, however, they are heavier. • Plastic: Lenses that are lighter weight and more comfortable, however they scratch more easily.

Progressive: Lenses that are line-free. The power gradually changes from distance correction to arm’s length to reading, moving invisibly from the top to the bottom of the lens. Standard progressive lenses use older technology, while premium progressive lenses use more current technology. Premium progressive lenses allow for a smoother blending in the lens as the prescription changes and may also provide clearer peripheral vision.

Plano: Lenses that do not have any correction and are often used for cosmetic purposes.

High-Index: Lenses that have a higher index of refraction, meaning light travels faster through the lens to reach the eye than with traditional glass or plastic. They are denser so the same amount of visual correction occurs with less material. This allows the lens to be thinner and look better cosmetically.

Polycarbonate: The most durable lens on the market. They are especially popular for children’s prescriptions and industrial safety glasses because of the protection they provide against breakage.

Photochromic: Lenses that change from light to dark depending on the intensity of ultraviolet light exposure. This option is often sold under the “Transitions” brand.

Polarized: Lenses that reduce the glare from water and other flat surfaces making the outdoor experience more pleasant and easier on the eye. Boaters and fishermen appreciate this type of lens.

UV Protection: A treatment is applied to lenses to block the harmful portion of ultraviolet light in sunlight.

Scratch-Resistance: A coating applied to plastic lenses to increase their resistance to scratching and pitting. While no lens is ever entirely “scratchproof,” a scratch-resistant coating reduces the chance of lens scratching.

Anti-Reflective: A coating applied to lenses to reduce the intensity of reflections. Bright lights from cars or computer screens, for example, are minimized. They also reduce the intensity of reflections that other people see on the front surface of the lenses so they are more cosmetically appealing.

Solid Tints and Dyes: Lenses with solid color tints and dyes have the same color density throughout. Plastic lenses can be dyed, while tinted glass lenses are made from colored glass. These options may be selected for cosmetic purposes or to reduce the amount of light coming through the lenses.

Plastic Gradient Dyes: Lenses with plastic gradient dyes are usually dark at the top and gradually lighten toward the bottom of the lens. This option is typically for cosmetic purposes.

High-Luster Edge Polish: Glass and plastic lens edges can be polished to a high luster resulting in clear and shiny lens edges. This option is often selected with rimless frames to disguise the edges of the lenses, especially with thicker lenses.

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Can I get Medicare Part B when I turn 65 if I am disabled and only have Part A? Can I get any other kinds of Medicare if I’m disabled?

If you’re disabled and received Medicare Part A before age 65 but did not accept Part B at that time, you may be automatically enrolled in Medicare Part B when you reach your 65th birthday. You will receive a new Medicare card showing the Part A entitlement date based on disability and the Part B entitlement date based on aging into the program.

You will receive the card about three months prior to the month you turn age 65. You won’t have to pay a late-enrollment fee for Medicare Part B, but you will be responsible for paying the Part B monthly premium if you choose to keep that coverage. The package you receive before your 65th birthday will explain how you can decline Part B if you don’t want it.

Keep in mind that you need to be enrolled in Medicare Part B to qualify for certain Medicare plan options, such as Medicare Advantage and Medicare Supplement (Medigap) insurance. If you delay Part B enrollment, you might face a late-enrollment penalty when you enroll later on.

To qualify for Medicare, whether by age or disability, you must be an American citizen or permanent legal resident of at least five years in a row.

Medicare options for those under age 65 with a disability

If you’re under age 65 with a disability and receive disability benefits from the Social Security Administration (SSA) or the Railroad Retirement Board (RRB) for 24 straight months, then you will automatically be enrolled in Original Medicare, Part A and Part B.

There are some other situations where you may qualify for Medicare before age 65:

  • If you have ALS (amyotrophic lateral sclerosis, also called Lou Gehrig’s disease), then you will automatically get Medicare Part A and Part B on the month that your SSA or RRB disability benefits begin.
  • If you have end-stage renal disease (ESRD), you may qualify for Medicare, but you’re not enrolled automatically. Contact the SSA (information below) to apply for Medicare.

Once you qualify for Original Medicare, Part A and Part B, you may want to consider additional or alternative Medicare coverage. For example, you can receive your Medicare benefits through a Medicare Advantage plan from a private insurance company that contracts with Medicare. There are several types of Medicare Advantage plans, and in addition to providing your Medicare Part A and Part B benefits, many plans offer additional benefits, such as prescription drug coverage. You continue paying your Part B premium, as well as any Medicare Advantage plan premium.

Not every Medicare Advantage plan accepts applicants with ESRD. Those with ESRD may be able to enroll in a Medicare Advantage Special Needs Plan tailored to that disease, provided one is available in your coverage area. There may be other exceptions, so call any plan you’re considering and ask if it would cover you.

If you need prescription drug coverage, and you’re not enrolled in a Medicare Advantage Prescription Drug plan, you can sign up for a stand-alone Medicare Part D Prescription Drug Plan once you have Medicare Part A and/or Part B and live in the plan’s coverage area.

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How does Drug Card America work?

The Drug Card America Card is a non-insurance discount card that provides saving solutions for individuals and family members living in their home. The purpose of providing you with this card is to minimize your “out-of-pocket” expenses for your prescriptions. This program offers up to 60% savings on select generics and up to 15% savings on select name brand prescriptions. The discount fees are honored at participating pharmacy providers. To see which pharmacies in your area accept the card, please click here.

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What is the Medicare coverage for eye care and eyeglasses?

Generally, Original Medicare does not cover routine eyeglasses or contact lenses. However, following cataract surgery that implants an intraocular lens, Medicare Part B helps pay for corrective lenses; one pair of eyeglasses or one set of contact lenses provided by an ophthalmologist.

Post-cataract services provided by an optometrist may be covered, if the optometrist is licensed to provide this service in your state, and:

  • Medicare will pay only for standard frames.
  • Eyeglasses and contact lenses are covered even if you had the surgery before you had Medicare.
  • Both eye lenses may be covered even if you had your cataract surgery on one eye only.

A prescription order signed by your doctor (ophthalmologist or optometrist) must be on file with the supplier. Suppliers must be enrolled in Medicare and must meet strict standards to qualify for a Medicare supplier number. Medicare won’t pay your claim if your supplier doesn’t have a number, even if your supplier is a large chain or department store that sells more than just durable medical equipment (DME).

After each cataract surgery with an intraocular lens, you pay 20% of Medicare-approved amounts for one pair of eyeglasses or one set of contact lenses, after the Part B deductible, if applicable.

Medicare will only reimburse or pay for the standard eyeglass frame amount. You pay an additional cost for upgraded frames.

For more information about Medicare eye care, you may call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week.

Note: Ask if the supplier is a participating supplier in the Medicare program before you get durable medical equipment. If the supplier is a participating supplier, it must accept assignment. If the supplier is enrolled in Medicare but isn’t “participating,” it has the option to accept assignment.

If the supplier isn’t enrolled in Medicare, Medicare won’t pay your claim.

Glaucoma screening

Medicare Part B covers a glaucoma screening test once every 12 months for people at high risk for glaucoma. This includes people with diabetes, a family history of glaucoma, African Americans who are age 50 or older, and Hispanic Americans who are age 65 or older. The screening must be done or supervised by an eye doctor who is legally allowed to do this service in your state.

You pay 20% of Medicare-approved amounts, and the Part B deductible applies.

Routine eye exams

Routine eye exams are not covered by Medicare, including eye refractions. However, some preventive eye tests and screenings, such as glaucoma screening and treatment of macular degeneration, are covered.

You pay 100% out-of-pocket under Original Medicare for routine eye exams.

Treatment of macular degeneration

Medicare Part B will cover certain diagnostic tests and treatment of diseases and conditions of the eye, which include treatment with certain injected drugs. Some people with age-related macular degeneration (AMD) are covered by Medicare. You would be responsible for 20% of Medicare-approved amounts for diagnosis and treatment of diseases and conditions of the eye after the Part B deductible is applied.

Eye prostheses

Eye prostheses are covered for patients with absence or shrinkage of an eye due to birth defect, trauma or surgical removal. Medicare covers polishing and of the artificial eye, and typically covers replacement every five years.

You pay 20% of Medicare-approved amounts after the Part B deductible is applied.

Medicare Advantage plans and vision coverage

While Original Medicare coverage of routine vision care is limited, some Medicare Advantage plans may include additional vision benefits. Medicare Advantage plans are required to provide at least the same level of coverage as Medicare Part A and Part B, but many plans also cover additional benefits that go beyond Original Medicare, which may include routine dental or eye care.

Under a Medicare Advantage plan, vision benefits may include:

  • Preventive eye exams covered under Original Medicare
  • Routine eye exams
  • Eyeglasses (frames and lenses)
  • Contact lenses

Keep in mind that the specific benefits may vary, depending on the Medicare Advantage plans available in your service area. For more information, check with the individual health plan you’re considering. If you’d like help finding a Medicare Advantage plan that includes vision benefits, you can visit Medicare.gov or call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week (TTY users, call 1-877-486-2048.

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Do the plans include any waiting periods before benefits are available?

No.  The vision plans do not have any waiting periods for any of the benefits available.

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Is MDLIVE appropriate for every medical condition?

No. MDLIVE is designed to handle non-emergency medical issues. You should not use MDLIVE if you are experiencing a medical emergency. In case of a medical life threatening emergency, you should dial

911 immediately. While MDLIVE is not intended to replace your primary care doctor for common or chronic conditions, a virtual doctor’s appointment can sometimes substitute a doctor’s office, urgent care, or an emergency room visit.

 

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Why did I receive a notice (bill) for my Medicare premiums?

Most people get Medicare Part A for free if they’ve worked at least 10 years (40 quarters) and paid Medicare taxes; otherwise, you can purchase Part A and pay a monthly premium for it, which will vary depending on your work history and the number of employment quarters you have. If you do not qualify for premium-free Medicare Part A and you choose to buy Part A, then you will be charged for your premium, also known as a “Notice of Medicare Premium Payment Due.” You may get a bill, or it may be deducted from your monthly benefits as described below.

Medicare Part B comes with a monthly premium unless you qualify for financial assistance. If you get help with Medicare costs through a state Medicaid program, such as a Medicare Savings Program, then your Medicare premiums may be paid for by the state. However, if you don’t qualify for Medicaid and enroll in Medicare Part B, you may receive a bill for your Medicare premiums, or it may be automatically deducted from your monthly benefits as described below.

If you receive benefits from the Social Security Administration, the Railroad Retirement Board, or the Civil Service, then your Medicare premiums will be deducted from your monthly benefit payment. Otherwise, you have several options when it comes to paying your Medicare premiums, including automated payments from a bank account or mailing a check or credit card payment to the Medicare Premium Collection Center. For more information, see this article on how to pay your Medicare premiums.

You may have to pay an additional premium if you’re enrolled in a Medicare Prescription Drug Plan, Medicare Supplement (Medigap) plan, or Medicare Advantage plan. In this case, your Medicare plan will send you a bill for your premium, and you’ll send the payment to your plan, not the Medicare program. Some Medicare Advantage plans may offer premiums as low as $0. However, remember that regardless of whether you owe a premium for your Medicare plan, you’ll need to keep paying your Medicare Part B premium.

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What are frames?

Lenses provide function, and frames provide style. There are all kinds of frames on the market that vary in size, shape, and color. Some people prefer bigger, some smaller, but what is most important is that the frame works with the style of lens.

Members often request prescription safety glasses, sunglasses, or ski goggles. It is important for members to verify whether these items are covered under their specific plan benefits.

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Do I get Medicare if I’m getting Social Security disability benefits?

You will typically be automatically enrolled in Original Medicare, Part A and B, after you’ve received Social Security disability benefits (or certain Railroad Retirement Board disability benefits) for two straight years. Your Medicare coverage will start 24 months from the month you qualified for disability benefits. In some cases, this could be earlier than the month when you received your first check. You must be either a U.S. citizen or legal permanent resident of at least five continuous years to be eligible for Medicare.

Note that certain conditions may qualify you for Medicare under age 65, but have different enrollment details than those described above.

  • If you have Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis, or ALS), you’re enrolled in Medicare automatically the first month you receive disability benefits from Social Security or the Railroad Retirement Board.
  • If you have end-stage renal disease (ESRD), you might qualify for Medicare, but you’re not automatically enrolled. If you’re on dialysis or you’ve had a kidney transplant, contact Social Security (information below).

You can get more information about Medicare and Social Security disability benefits from the Social Security Administration:

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Who will benefit using Drug Card America?

Members can use the card for his/her personal benefit or the benefits of his/her spouse, dependent children and any permanent resident in the member’s household.  There is no cost to join, just print off the card and enter your name and family members that wish to save on prescriptions.

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Does Original Medicare cover eye exams?

Original Medicare, Part A and Part B, does not generally cover routine eye exams for eyeglasses or contact lenses. However, Medicare Part B will cover an annual eye exam every 12 months if you have diabetes or are at high risk for glaucoma. Part B coverage also includes diagnostic tests and treatment for certain eye diseases, such as lucentis, aflibercept, and ocular photodynamic therapy.

Because Medicare Advantage plans must offer at least the same coverage as Original Medicare, these plans (offered by private, Medicare-approved insurance companies) also cover the circumstances described above. However, some Medicare Advantage plans may offer additional coverage, which could include routine vision benefits. Certain Medicare Supplement (Medigap) plans may also cover vision-related costs or provide additional eye coverage for an extra cost.

You can type your zip code into the form on this page to see a list of Medicare plans in your vicinity. To speak with one of eHealth’s licensed insurance agents, just call eHealth at the phone number below this article.

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If I have coverage through my spouse or another plan, does your plan coordinate benefits?

Yes. If you have coverage other another group vision plan, Ameritas will coordinate the benefits between the two plans.   If you are covered as a dependent under a spouse’s plan, the NAR plan would be considered “Primary” for you as the NAR member, and “Secondary” under your spouses plan.   Your spouse would be considered “Primary” under their own coverage and”Secondary” under your NAR plan.   Note:  by coordinating benefits, the benefit between the two plans would equal no more than 100% of the total cost of the service.

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What are the most common conditions you treat?

Our doctors are trained to treat a wide range of conditions.

Some of the most common are:

  •  Acne
  • Allergies
  • Asthma
  • Bronchitis
  • Cold & Flu
  • Constipation
  • Diarrhea
  • Ear Infection
  • Fever
  • Headache
  • Insect Bites
  • Joint Aches
  • Nausea
  • Rashes
  • Sinus Infections
  • Sore Throat
  • UTI
  • and more!

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How can my Medicare plan premium be zero dollars ($0) or have no premium?

All Medicare Advantage plans offer, at minimum, the same coverage as Original Medicare, Part A and Part B. These plans are sold by private insurance companies with the ability to set their own prices and must be approved by the Centers for Medicare & Medicaid Services (CMS).

However, although a Medicare Advantage plan may offer a monthly premium as low as $0, you should keep in mind that there may be other costs you could be responsible for. If you are enrolled into a Medicare Advantage plan, you will need to continue paying your Medicare Part B premium. Additional costs you may be responsible for include prescription drug costs, copayments, coinsurance, and annual deductibles. It is recommended that beneficiaries compare all of the different costs associated with Medicare Advantage plan coverage before enrolling into a plan in their service area.

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What are the types of contact lenses and definitions?

Contact Lenses

Contact Lenses – Necessary: When eyeglasses do not achieve the best visual potential, contact lenses may become necessary. This can be due to keratoconus, corneal trauma, or postsurgical irregularity in the corneal surface.

Contact Lenses – Elective: Many patients choose to wear contact lenses even though glasses achieve a full visual correction. This is considered an elective situation.

Contact Lens Options

Soft Contacts

  • Daily Wear: Lenses are worn during the day and removed each night to be cleaned and disinfected.
  • Extended Wear: Lenses are worn at night, but they must be removed for cleaning and disinfecting at least once a week.
  • Disposable: Lenses are worn during the day and removed at night. They don’t need to be cleaned or disinfected, but are used for the recommended time-frame and then discarded.

Rigid Contacts

  • Gas Permeable: Rigid lenses that, unlike “hard lenses” of the past, allow oxygen to pass through to the eye to keep it healthy. Gas permeable lenses provide better vision, durability, and deposit resistance than soft contact lenses.
  • Ortho-K: A type of lens used to reshape the cornea so that when removed, regular vision is improved, although the effect is temporary. These lenses are also referred to as “night time contacts.”

Specialized Contacts

  • Toric: Lenses are specially shaped and fitted to treat astigmatism.
  • Multifocal: Correct nearsightedness, farsightedness, and astigmatism.
  • Tinted: Contacts can be tinted, either for cosmetic or therapeutic purposes. An example of a therapeutic purpose is to enhance color perception to help compensate for color blindness.

 

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Can i get a Medicare Advantage plan and Medicare Prescription Drug plan at the same time?

First, a quick rundown on what Medicare Part C and Part D refer to.

Medicare Part C refers to Medicare Advantage, an option that provides an alternative way to get your Medicare benefits. Offered by private insurance companies approved by Medicare, Medicare Advantage plans must provide the same coverage that Original Medicare, Part A and Part B, cover — but many Medicare Advantage plans offer extra benefits (such as routine vision services).

Most Medicare Advantage plans include prescription drug coverage. These plans are known as Medicare Advantage Prescription Drug plans.

Medicare Part D refers to prescription drug coverage that’s available as a stand-alone plan. Because Original Medicare (Part A and Part B) doesn’t cover prescription drugs except in limited situations, you might consider enrolling in a stand-alone Medicare Part D Prescription Drug Plan to augment your Original Medicare coverage. These plans are available from private, Medicare-approved insurance companies.

Usually, if you have Medicare prescription drug coverage, you’re either enrolled in Original Medicare and in a Medicare Part D Prescription Drug Plan, or a Medicare Advantage Prescription Drug plan.

If your Medicare Advantage plan doesn’t have prescription drug coverage, you might be allowed to add a Medicare Prescription Drug Plan. But you may want to contact your Medicare Advantage plan before making any changes.

Bottom line: If your Medicare Advantage plan includes prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D Prescription Drug Plan at the same time.

You might want to consider the following options if your Medicare Advantage plan does not include prescription drug coverage:

  • Change to a different Medicare Advantage plan that includes prescription drug coverage.
  • Drop your Medicare Advantage plan and go back to Original Medicare (Part A and Part B), and add a Medicare Part D Prescription Drug Plan.

You cannot add or drop Medicare plans anytime; you can do this only during certain time periods.

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What savings do I get as a participant with Drug Card America?

This program offers up to 60% savings on select generics and up to 15% savings on select name brand prescriptions.

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Does Original Medicare cover dentures?

No. Original Medicare does not cover dentures. In general, Medicare does not cover any routine dental care, including cleanings or check-ups, and never pays for dentures. It may cover the cost of teeth extraction before an inpatient procedure, but will not cover the cost of dentures after the procedure. For example, if you broke your jaw, then Original Medicare would cover any teeth extraction related to the jaw injury.

Certain Medicare plan options offered by private Medicare-approved insurance companies — such as Medicare Advantage plans — might offer dental coverage. Our free, no obligation eHealthMedicare plan comparison tool on this page can help you find available Medicare Advantage and Medigap plans in your area. Enter your zip code to review a list of plans. If routine dental care is covered, it will be shown by a tooth icon beneath the “coverage included” area on the results page.

Even if several Medicare plans offer routine dental coverage, the specific details may vary across plans. You may want to compare all the ones in your area, calling each one if necessary, to determine which plan offers the dental coverage you need.

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What does REALTORS Vision Insurance cost?

Members of the NAR have access to exclusive plans and rates for vision insurance that provides benefits for eye exams, frames, lenses, contacts, and more.  To get a quote; simply complete the quote request form on www.realtorsinsurancemarketplace.com or call our customer service team at 877-267-3752.

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Why should I buy a REALTORS® Dental Insurance plan through NAR?

Many self-employed find it difficult to buy individual dental insurance. And if a plan can be found, the pricing for an individual plan can be very expensive. REALTORS® Insurance Marketplace is proud to offer REALTORS® Dental Insurance, an group dental plan offered exclusively to REALTORS® that brings members a choice of affordable plan options. We encourage members to review the four plan choices to consider which plan best fits their budget and dental care needs.

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How do I sign up for MDLIVE and activate my MDLIVE account?

You can easily sign up and activate your account by using one the following methods:

1. Go online and visit: mdlive.com/sas
2. Call our toll free number: 1-888-632-2738
3. Download our Mobile App, available on the iTunes store and Google Play.

 

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I’ve noticed that Medicare Advantage plans have a maximum out-of-pocket limit. Is that a deductible?

The out-of-pocket maximum for Medicare Advantage plans is not a deductible; it is the highest yearly amount you will have to pay out of pocket for covered health-care services. This spending maximum is one important difference between Medicare Advantage plans and the traditional fee-for-service Medicare program; Original Medicare doesn’t have a yearly cap on your health-care costs.

This yearly cap does not include monthly premiums, but annual deductibles, coinsurance, and copayments may all count towards this maximum limit. The out-of-pocket maximum may be different for each individual Medicare Advantage plan and can change from year to year. Once you have reached the plan’s spending limit for that year, then your Medicare Advantage plan will cover 100% of covered health-care costs for the rest of the year.

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What are employment quarters?

Understanding what employment quarters are and how they are calculated is useful because this can determine whether or not you need to pay a premium for Medicare Part A. This part of Medicare covers many hospital services and is typically premium-free for people over 65 years of age if they are also eligible for retirement benefits from Social Security or the Railroad Retirement Board.

Employment quarters are a period of time used as part of the calculation for your Social Security or Railroad Retirement Board benefits when you retire. In general, you may qualify for these benefits by earning credits when you work in a job and pay Social Security or Railroad Retirement Board taxes.

Most of the time, you are also paying Medicare taxes, so the same employment quarters or credits add up to your contribution towards Medicare when you reach age 65. Medicare Part A is funded largely by payroll taxes paid by employees, employers, people who are self-employed, and Medicare Part A premiums.

What are employment quarters for Social Security?

The Social Security Administration calls employment quarters by several names, such as “quarter of coverage” and “Social Security credits” or simply “credits.”

How credits for Social Security retirement benefits (and thus, Medicare benefits) have been calculated has changed over the years. Today, Social Security credits are based on your total income during the year, and the year is divided into four employment quarters.

The dollar amount needed to earn credits may go up slightly each year, according to the Social Security Administration, as average earnings increase. For more information on the current earnings needed to earn Social Security or Medicare work credit, visit the Social Security website.

There are special rules for certain types of jobs, such as domestic work, farm work, and work for a church or similar organization that does not collect Social Security and Medicare taxes. Employment of this sort may count towards your employment quarters for retirement and Medicare benefits, but you should contact the Social Security Administration to confirm. Conversely, some people may not qualify for Social Security retirement credits, such as federal employees hired before 1984, railroad employees with more than 10 years of service, and employees of some state and local governments. Other factors may be used to determine their eligibility for premium-free Medicare Part A.

What are employment quarters for the Railroad Retirement Board?

If you worked for a railroad, your retirement benefits are calculated by how many calendar months you worked. Beginning at age 60 and with a minimum 360 months of railroad service, you may qualify for a retirement annuity.

How many employment quarters do you need to have worked to get premium-free Medicare Part A?

For the Social Security Administration, the number of employment quarters that qualify you for retirement and premium-free Medicare Part A depends on your date of birth. If you were born in 1929 or later, you need 40 credits (equal to 10 years of work). If you were born in 1928, you need 39 credits, and the amount decreases as the date goes further back — those born in 1927 need 38 credits, etc.

If you were a railroad employee and you qualify for the minimum railroad retirement annuity noted above, you’re likely to qualify for premium-free Medicare Part A. That length of service should provide equivalent employment quarters and Medicare taxes.

Qualifying for premium-free Medicare Part A through your spouse’s employment

If you have never worked or have not worked enough employment quarters to qualify for premium-free Part A and you’re married, you might gain this benefit through your spouse’s employment history. If your spouse receives Social Security retirement benefits or Railroad Retirement Board benefits, you can apply to Medicare when you’re eligible, and you may get Part A without paying a premium.

While Part A often has no premium, Medicare Part B usually does, whether you apply based on your employment history or your spouse’s. Together, Part A and Part B make up Original Medicare. You can get these benefits through the federal program or through private insurance companies that offer Medicare Advantage plans, also called Medicare Part C. There is also Medicare Part D prescription drug coverage (Medicare Prescription Drug Plans) and Medicare Supplement insurance (Medigap) sold by private insurance companies, and you can add these to your Original Medicare, if you wish.

Because Medicare has many parts, it’s important to understand how they work together and what benefits may be right for you.

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When can I start using my benefits with Drug Card America?

You can start to save instantly.  Just print off the card, enter your information and give to a participating pharmacy.  They will enter you in their system as belonging to the Drug Card America group.  You begin to save immediately.

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Why doesn’t Medicare cover dental care, hearing aids, and eyeglasses?

Original Medicare, Part A and Part B, doesn’t cover everything. Routine dental care, hearing aids, and eyeglasses are statutorily excluded from Medicare coverage. It would take an act of Congress to include routine dental services, hearing aids, and eyeglasses in Medicare program coverage.

Medicare coverage of dental care

Medicare doesn’t cover routine dental care, such as oral exams, cleanings, fillings, bridges, or crowns. However, there are a few situations where you may be covered for dental services:

  • Dental services may be covered if they are an essential part of another Medicare-covered procedure. For example, if you hurt your jaw in an accident, Medicare may cover jaw reconstruction if it is medically necessary to treat your injury.
  • Medicare may cover extraction of teeth to prepare the jaw for radiation treatment for jaw-related neoplastic diseases.
  • Medicare may cover dental examinations prior to a complicated procedure (such as a kidney or heart transplant) that requires an oral exam. You’ll be covered under Medicare Part A or Part B, depending on whether the oral exam is performed in an inpatient or outpatient setting.

Some Medicare Advantage plans may include benefits beyond what Original Medicare covers, including routine dental services. Medicare Advantage plans vary in terms of the benefits covered, so check with the specific plan if you’re interested in dental coverage.

Medicare coverage of hearing aids

Medicare doesn’t cover hearing aids or exams to get fitted for them. You’ll pay 100% of the cost if you have Original Medicare, Part A and Part B.

You may be able to get coverage for hearing care (including hearing aids) through a Medicare Advantage plan. Since benefits vary, check with the individual Medicare Advantage plan.

Medicare coverage of eyeglasses

Medicare doesn’t typically cover eyeglasses or contact lenses. However, Medicare Part B may cover corrective lenses after you have cataract surgery to implant an intraocular lens. You’ll be covered for either one set of glasses or contact lenses following your surgery if you get these items from a supplier that is enrolled with the Medicare program. If you upgrade your frames, you’ll pay any extra costs.

In most other situations, you’ll pay the full cost for eyeglasses and contact lenses. You may be able to get coverage for routine vision services (including glasses or contact lenses) through a Medicare Advantage plan.

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Who files a claim under my coverage?

Simply provide your ID card to your vision provider. While all PPO providers are required to file claims on your behalf, many non-participating providers offer claim filing services as well. Once the claim is filed, you will receive an Explanation of Benefits (EOB) from the administrator explaining what was paid and what you owe the provider.

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When can I start using my MDLIVE service?

You can start using MDLIVE immediately after you sign up and activate your account. Sign up, activation, and doctor consults are free. Once you have an MDLIVE account, you can browse doctor profiles, view available appointment times, and schedule an appointment with the doctor of your choice.

Want to go one step further? Be sure to fill out your medical history profile to better prepare your MDLIVE doctor for your appointment.

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Will my secondary insurance pay for my Medicare deductible and/or 20% coinsurance?

Beneficiaries who are enrolled in more than one insurance plan have more than one “payer,” which means that “coordination of benefits” rules determine which payer pays first. The primary payer pays what it owes on your claim first while the secondary payer pays its part of the remainder of the claim.

Original Medicare, Part A and Part B, is considered a primary payer when a beneficiary does not have additional insurance.

Beneficiaries enrolled in Original Medicare may choose to enroll in a Medicare Supplement plan to fill in the gaps in coverage and cover some of the costs of care not covered through Original Medicare. Some Medicare Supplement plans cover the out-of-pocket costs associated with Original Medicare, such as deductibles and coinsurance payments. Therefore, some Medicare Supplement plans may pay for your deductible and/or your coinsurance and/or other out-of-pocket costs not covered by Original Medicare. Contact your Medigap plan directly to see if it covers these costs.

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What is the Initial Enrollment Questionnaire(IEQ) and where do I find it?

The “Initial Enrollment Questionnaire” (IEQ) is a form that Medicare sends to individuals who are newly eligible for Medicare. The questionnaire asks about other health insurance you may have that may pay for services before Medicare, such as an employer health plan or workers’ compensation. New beneficiaries need to fill out IEQs upon enrolling into Medicare.

You may complete the IEQ online or via telephone.

Online

Three months prior to when your coverage begins, Medicare will send you a letter in the mail with a username, temporary password, and instructions on how to fill out an IEQ online at MyMedicare.gov.

Telephone

Beneficiaries have the option of completing the IEQ over the phone by calling the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627 (TTY users 1-877-486-2048).

You will have up to 180 days after your Medicare effective date (the date your coverage begins) to submit the form.

Where can you get more information?

  • Visit Medicare.gov to view or print Medicare publications and find helpful phone numbers and resources.
  • Call 1-800-MEDICARE or 1-800-633-4227 (TTY 1-877-486-2048), available 24 hours a day, seven days a week.
  • Visit Medicare.gov/publications to view or print the booklet “Medicare and Other Health Benefits: Your Guide to Who Pays First.” You can also call 1-800-MEDICARE to request a copy.
  • Call your State Health Insurance Assistance Program (SHIP) for free health insurance counseling and personalized help. To get the most up-to-date SHIP phone numbers, visit Medicare.gov.

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How do I locate a participating provider in the network for Drug Card America?

There are two ways to locate participating providers, You can do an online pharmacy lookup (click here) or Call SASid customer service at toll free 1-877-267-3752.

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What diabetic supplies are covered by Original Medicare?

Original Medicare Part B covers some diabetic supplies, including:

  • Blood sugar (glucose) test strips
  • Blood glucose monitors, lancet devices, and lancets
  • Glucose control solutions for checking the accuracy of test strips and monitors
  • Insulin if you are using a medically necessary insulin pump (see below)
  • Therapeutic shoes or inserts (see below)

There may be coverage limits on the quantity and frequency you can get these supplies.

Original Medicare Part B does not cover these diabetic supplies:

  • Insulin (unless used with an insulin pump)
  • Insulin pens, syringes, or needles
  • Alcohol swabs or gauze

About insulin coverage

  • If you use a medically necessary external insulin pump, the insulin and the pump could be covered as durable medical equipment (DME).
  • If you do not use a pump, you pay for all of your insulin costs.
  • If you have Medicare prescription drug coverage (Medicare Part D), insulin and certain medical supplies used to inject insulin are covered.

About therapeutic shoes and inserts

Medicare Part B coverage includes therapeutic shoes or inserts for diabetics who have certain conditions — ask the doctor who treats your diabetes if you need them. To make sure these supplies are covered by Medicare, please note:

  • A qualified doctor (such as a podiatrist) must prescribe the shoes or inserts.
  • A qualified doctor (such as an orthodontist) must provide and fit you for the shoes or inserts.
  • Medicare Part B covers one pair of custom-molded shoes (including inserts) or one pair of depth-inlay shoes per calendar year.
  • Medicare also covers two additional pairs of inserts each calendar year for custom-molded shoes and three pairs of inserts each calendar year for depth-inlay shoes.
  • In certain cases, shoe modifications may be substituted for inserts.
  • The supplier must have an order (prescription) on file signed and dated by the treating doctor; if you switch to a different supplier, you may need to have your prescription transferred or get a new prescription from your doctor. Make sure your supplier is enrolled in Medicare.

Other useful information

  • Generally, you pay 20% of Medicare-approved amounts for your supplies, and the Medicare Part B deductible applies.
  • Make sure you refill your supplies in a timely manner, and only accept supplies you have requested. Medicare won’t pay for supplies you didn’t order; for example, if a supplier automatically sends you items, you cannot get reimbursed by Medicare.
  • You may rent or purchase certain diabetic supplies. For more information, call 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. Customer service representatives are available 24 hours a day, seven days a week.
  • Ask if the supplier is a participating supplier in the Medicare program before you get durable medical equipment (DME) for diabetes. If the supplier is a participating supplier, he or she must accept assignment. If the supplier is enrolled in Medicare but isn’t “participating,” he or she has the option to accept assignment or not. If a DME supplier doesn’t accept Medicare assignment, there is no limit to what you can be charged. You also may have to pay the entire bill (your share and Medicare’s share) at the time you get the DME.
  • All Medicare-enrolled pharmacies and suppliers must submit claims for diabetic testing supplies. You can’t send in the claim yourself.

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Will I receive an ID card?

The ID cards and policy are mailed out to your residence, typically within 3 days via USPS. You should receive the policy and ID cards within two weeks.  If your provider does not accept the insurance you may obtain a claim form and submit the claims directly to Ameritas for processing.

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When is MDLIVE available?

MDLIVE is available 24 hours a day, 7 days a week, and 365 days a year, even on holidays. Use MDLIVE anytime you have a non-emergency medical condition, are unable to see your primary care provider, or when you simply prefer a convenient, cost effective alternative to the emergency room, urgent care center, or clinic.

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What does “primary insurance status” mean?

Medicare beneficiaries may have other insurance coverage in addition to their Medicare plan. When an insurance company has “primary insurance status,” it means that that insurer will pay on the beneficiary’s health-care claims first, while Medicare pays second. Please note that regardless of whether Medicare or the other insurance pays first, you will still be responsible for cost sharing associated with each. This refers to out-of-pocket costs paid by the beneficiary and may include any deductibles, copayments, and/or coinsurance costs required for covered services, both for Medicare and your other insurance.

Other types of insurance you may have include:

  • Auto insurance
  • Black lung benefits
  • Group health plans under certain conditions*
  • Homeowner’s insurance
  • Workers’ compensation
  • COBRA
  • Veterans’ benefits
  • TRICARE

If you do not have any of the above types of insurance and do not have another type of insurance listed as the primary payer, then Medicare is your primary insurance. In this scenario, your doctor or health provider will generally submit a claim to Medicare first before billing you for your share. You will still be responsible for paying the Medicare deductible, coinsurance, and copayment amounts for covered services.

If a beneficiary’s other insurance has primary insurance status but does not pay first in time, Medicare may make a conditional payment and then recover the payments from the primary insurer later.

*A group health plan may be the primary payer under some situations if specific conditions are met. For example, one situation where the group plan would pay first if a) the beneficiary has end-stage renal disease (ESRD) and is covered under a group plan, and b) the beneficiary is in the first 30 months of Medicare eligibility or entitlement. This isn’t the only situation where your group health plan may pay first. For a list of common situations where Medicare might be a primary or secondary payer, see this publication, “Your Guide to Who Pays First.” If you have questions about how Medicare works with other insurance you may have, contact the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627; TTY users should call 1-855-797-2627.

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Do I have to submit the Initial Enrollment Questionnaire(IEQ) online?

The Initial Enrollment Questionnaire (IEQ) asks you about other health insurance coverage you may have that might pay before Medicare pays, such as employer-sponsored group coverage, veterans benefits, or workers’ compensation benefits. You don’t have to submit your Medicare Initial Enrollment Questionnaires (IEQ) online, but this is the fastest way for Medicare to get your form. If you complete the IEQ form online, the information will be transmitted electronically to the Coordination of Benefits Contractor immediately after you submit the form.

If you’re having trouble submitting the form online or prefer to do by phone, you can call the Benefits Coordination & Recovery Center (BCRC) to submit the form over the phone. You can reach the BCRC at 1-855-798-2627 (TTY users 1-855-797-2627), Monday to Friday, from 8AM to 8PM Eastern Time.

Medicare doesn’t mail the Initial Enrollment Questionnaire to you, but it sends you a letter with your MyMedicare.gov login information and instructions on how to complete the questionnaire online. This letter will arrive three months before your Medicare coverage begins. Your Initial Enrollment Questionnaire will be available on MyMedicare.gov 90 days before your Medicare coverage starts, and you have up to 180 days after your coverage begins to submit the form.

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Is there a Medicare deductible?

Original Medicare has two parts: Part A for hospital insurance and Part B for medical insurance. Each covers different services and has different costs for the beneficiary. Both Part A and Part B have deductibles that you may need to pay before certain benefits are covered.

Medicare Part A deductible

Medicare Part A benefits include inpatient hospital care, skilled nursing facility care, home health services, and hospice.

For a hospital stay, you usually have to pay the Part A hospital inpatient deductible, which is $1,288 in 2016 for each benefit period. You may have other costs for the specific health-care services you receive while in the hospital. On the 61st day of a hospital stay, you would also start to have coinsurance costs. Your coinsurance costs depend on the length of your stay:

  • Days 61 to 90: Daily coinsurance of $322 in 2016 for each benefit period
  • Days 91 and over: Daily coinsurance of $644 in 2016 for each “lifetime reserve day” in each benefit period (up to a maximum of 60 days over your lifetime)
  • After lifetime reserve days are used up: You pay all costs

For home health-care services, all costs are covered under Medicare Part A for a limited time under certain conditions. However, if your doctor orders durable medical equipment and supplies as part of your care, you’ll pay 20% of the Medicare-approved amount for the equipment.

For hospice care, all costs are covered, with some exceptions:

  • If you take prescription medications or similar items for pain relief or symptom control while on hospice, you may be responsible for a copayment of no greater than $5 per drug.
  • If you need inpatient respite services, you may need to pay 5% of the Medicare-approved amount for that care.
  • If you get hospice care in your own home or a nursing home, you’ll pay for room and board costs.

Medicare Part B deductible

Medicare Part B benefits include (but aren’t limited to) doctor’s office visits, preventive screenings, and durable medical equipment. For some of these services, a deductible will apply, and Part B deductible is $166 in 2016. Often, you will pay 20% of the Medicare-approved amount for a health-care service after this deductible is met. Make sure to check with your doctor and Medicare because each benefit’s coverage is different.

Medicare Supplement (Medigap) plans and Medicare deductibles

To get help paying for your Medicare deductibles, you might consider a Medicare Supplement (Medigap) plan. If you have Original Medicare, you can get this additional insurance to help cover some of your Medicare expenses. There are 10 standardized Medigap plans that are available in most U.S. states; Massachusetts, Minnesota, and Wisconsin have their own types of Medicare Supplement plans. Not every Medigap plan covers the Part A and/or Part B deducible, but most of the standardized plans cover at least one of these deductibles in full or partially.

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Is Drug Card America an insurance program?

No. This is not an insurance program. It is simply a way to obtain substantial savings on all of your prescription needs.

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What diabetic services does Medicare cover?

The first fact you need to know is that you must be enrolled in Medicare Part B for Medicare to cover your diabetic services or supplies. If you have a Medicare Advantage plan, you’re required to be enrolled in both Medicare Part A and Part B, so as long as you continue paying your Part B monthly premium, you should be covered as described below.

If you’re not sure whether you’re enrolled in Medicare Part B, look at your red, white, and blue Medicare card, or contact your current health insurance provider.

Medicare Part B covers the following diabetic services, generally requiring your Medicare-participating doctor’s order:

  • Diabetes screening: Medicare covers tests to check for diabetes if you’re considered at risk for the disease. These screenings may include tests such as a fasting plasma glucose test, or other Medicare-approved tests your doctor may order for you. Medicare may cover these screenings up to twice a year, depending on your risk factors.
  • Diabetes self-management training: For qualified beneficiaries, Medicare offers a training program that teaches you how to manage your diabetes. It includes education about self-monitoring of blood glucose, diet, exercise, and prescription medications. If you meet certain conditions, Medicare may cover 10 hours of initial diabetes self-management training, to be completed within a year, and two hours of follow-up training each following year.

A portion of the training is individual, with just you and your health instructor, but most of the training occurs in a group setting. There are exceptions that might qualify you for 10 hours of individual training: if you’re blind or deaf, have language limitations, or if no group classes have been available within two months of your doctor’s order for the training.

If you live in a rural area where you might have difficulty finding diabetes management training, it’s possible that you could get this training at a Federally Qualified Health Center (FQHC). For more information, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY users call 1-877-486-2048) 24 hours a day, seven days a week.

  • Yearly eye exam: Medicare covers annual eye exams to screen for diabetic retinopathy once every 12 months. These exams must be done by an eye doctor who is legally allowed to provide this service in your state.
  • Glaucoma screening: Medicare covers glaucoma screening once every 12 months for people at high risk for glaucoma: those with diabetes or a family history of the disease; African Americans age 50 and older; and Hispanic Americans age 65 and older. The test must be given or supervised by an eye doctor authorized in your state to administer the test.
  • Medical nutrition therapy (MNT) services: Medicare covers medical nutrition therapy services if you have diabetes or renal disease. To be eligible for this service, your fasting blood glucose has to meet certain criteria and your doctor must prescribe these services for you. These services can be given by a registered dietitian or Medicare-approved nutrition professional. They include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. Medicare covers 3 hours of one-on-one medical nutrition therapy services the first year the service is provided, and 2 hours each year after that. You may qualify for additional MNT hours of service if your doctor determines there is a change in your diagnosis, medical condition, or treatment regimen related to diabetes or renal disease and orders additional MNT hours during that episode of care.
  • Foot exam: Medicare may cover a foot exam every six months for people with diabetic peripheral neuropathy and loss of protective sensations, as long as you haven’t seen a foot care professional for another reason between visits. Medicare may cover more frequent visits to a foot care specialist if you’ve had a non-traumatic (not because of an injury) amputation of all or part of your foot, or if your feet have changed in appearance, which may indicate serious foot disease.
  • Hemoglobin A1c Tests: Your doctor might order a hemoglobin A1c lab test. This test measures how well your blood glucose has been controlled over the past 3 months. Medicare may cover this test for anyone with diabetes if it is ordered by his or her doctor.

About diabetes tests

Medicare covers diabetic screenings, or tests, if you have any of the following risk factors.

  • High blood pressure
  • Dyslipidemia (history of abnormal cholesterol and triglyceride levels)
  • Obesity (with certain conditions)
  • High blood sugar
  • Impaired glucose tolerance

Based on the results of these tests, you may be eligible for up to two diabetes screenings every year.

You typically pay 20% of Medicare-approved amounts for outpatient facility charges or doctor services. You pay nothing for preventive diabetes screenings.

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How do I cancel my coverage?

Vision insurance policy cancellation procedure:

We are confident that this vision plan is the best plan available of its kind. We do care about you and your health and it is our job to make sure that your have secured vision insurance that will benefit your needs. If you have not obtained other insurance and have questions about this plan and the benefits it can provide for you and your family, please contact our customer service department at 1-800-279-2290.

If you are confident that this vision insurance is not going to give you the benefits you need and you have met your twelve month commitment, or you have obtained new group vision coverage, you can terminate this plan. In order to avoid any future payments to be drafted from your account. We do require a hand written signature no later than five days before the next scheduled draft date.

If you are requesting to cancel your plan and are within your 10 day right to review period, your hand written request is required within ten days from the effective date requested on your application. If required information is received in a timely manner, a refund of your premiums paid minus any enrollment fees will be issued to the account on file.

Scan and Email request with signature to: adminefax@sasid.com
or
Fax # : 608-531-2707
or
Mail request to:
InsuranceTPA.com/SASid
PO Box 998
Janesville WI 53547

 

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Where is MDLIVE available?

MDLIVE is available anywhere in the United States**. Our network of Board Certified doctors will be provided to you based on the state you are located. We make sure that each doctor is fully licensed to practice medicine in your state. 

** MDLIVE services are limited to only phone consultations with the ability to prescribe in Iowa, Louisiana, and Texas. California permits both phone and video consultations with short term prescription limitations. Telehealth services are currently not available in Idaho. Please check back soon.

 

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About Medicare Appeals

There are several reasons why you might choose to file a Medicare appeal, but it generally boils down to a disagreement with a coverage or a payment decision. Whether you have Original Medicare (Part A and Part B), a private Medicare Advantage plan, or a Medicare prescription drug plan, you have the right to file an appeal in some situations.

If Medicare or your Medicare plan doesn’t cover a particular health care service, prescription drug, or piece of equipment that you feel it should, then you’re entitled to submit an appeal. Additionally, you can file an appeal for payment of a service, drug, or item that you already received, or request to change the amount you have to pay for any of those things. Finally, you have the right to appeal if Medicare or your Medicare plan stops providing or paying for all or part of any service, drug, or equipment you believe you still need.

Medicare beneficiaries enrolled in a Medicare Medical Savings Account (MSA) plan have the right to file an appeal if they believe that a service or item should count toward their deductible.

During an appeal

Whether you receive your coverage through Original Medicare or belong to a private Medicare Advantage or prescription drug plan, you can receive information on coverage details and costs ahead of your coverage start date so that you understand what’s covered by Medicare or your Medicare plan, and what your portion of costs will be.

If you choose to file an appeal, understand that you can seek additional help from your doctor and/or health-care provider or equipment supplier. Ask if he or she is willing to make a statement that supports your case.

The appeals process for Original Medicare, Part A and Part B, has five levels listed below (and explained in greater detail in this article). The five levels of the appeals process are as follows:

Level 1: Redetermination by a Medicare carrier, fiscal intermediary, or Medicare administrative contractor

Level 2: Reconsideration by a Qualified Independent Contractor (QIC)

Level 3: Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals

Level 4: Review by the Medicare Appeals Council

Level 5: Judicial review in federal district court

You might disagree with the decision(s) reached at the end of any level. If this happens, you can generally move onto the next level of appeal. If you’d like to do this, you’ll find instructions for doing so included in the current level decision letter.

If you belong to a private Medicare plan, you can contact your insurance company directly to find out the next steps when it comes to your Medicare appeal. Medicare.gov has more information on appeals.

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What is the Medicare Part B Special Enrollment Period for the working aged?

If you qualify for Medicare, but you have health insurance through an employer’s group health plan, you may be able to delay enrollment in Medicare Part B. When your employer-based coverage ends, you may be eligible for a Special Enrollment Period (SEP) to enroll in Medicare Part B without facing a late-enrollment penalty.

If you’ve worked at least 10 years (40 quarters) while paying Medicare taxes, you typically qualify for premium-free Medicare Part A. Since most Medicare beneficiaries pay a monthly Medicare Part B premium, some people choose not to enroll in Part B or to delay enrollment. Generally, you face a lifetime late-enrollment penalty for Part B if you sign up after you’re first eligible for Medicare.

However, Medicare has a Special Enrollment Period when you can enroll in Medicare Part B without a penalty. This is how your SEP works:

If all of these apply to you… …you may qualify for a SEP to enroll in Medicare Part B at any of these times:
– You’re 65 or older – While you are still covered by an employer or union group health plan
– You’re still working or your spouse is still working – During the eight months following the month when the employer or union group health plan coverage ends, or when the employment ends, whichever comes first.
– You’re covered by a health plan based on current employment

If you’re working and plan to keep your employer’s group health coverage, talk to your benefits administrator to help you decide when to enroll in Part B.

If your employer-based group coverage ends and you don’t enroll in Medicare Part B during the SEP, you have to wait until the General Enrollment Period to enroll and you may pay a higher Part B premium as a late enrollment penalty.

If you’re interested in enrolling in a Medicare Supplement (Medigap) plan, be aware that when your Part B coverage starts, your six-month Medigap Open Enrollment Period begins. Once this period begins, in most cases it cannot be changed or restarted.

Additionally, if you dropped Part B because you or your spouse (or family member, if you’re disabled) returned to work and had group health coverage, you can sign up for Part B again during the SEP described above and the Part B premium will not go up. Make sure your group coverage is active before you drop Part B. However, you generally will not get another Medigap Open Enrollment Period when you restart Part B.

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Is there a maximum use of the benefits with Drug Card America?

No. Unlike insurance, utilization is encouraged. You and your family may use the benefits as many times as needed. There are no limitations on usage.

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When can I add Part B to my Medicare?

Original Medicare, the government-sponsored health insurance program, includes Medicare Part A (hospital insurance) and Part B (medical insurance). Because Medicare Part B typically comes with a monthly premium, some beneficiaries delay enrollment in Part B (for example, if they have health coverage through employment), and may want to enroll in Part B later.

U.S. citizens and legal permanent residents of at least five continuous years may be eligible for Medicare coverage. You’re usually enrolled in Medicare Part A and Part B automatically when you turn 65 or qualify by disability at any age and you receive Social Security Administration (SSA) or Railroad Retirement Board (RRB) benefits. For details about how you qualify for automatic enrollment, see Medicare Enrollment.

You’re not automatically enrolled in Medicare Part B in all situations. Here are a few examples of when you may qualify for Part B, but you need to sign up manually:

  • If you live in Puerto Rico, you’re typically signed up for Medicare Part A automatically when you turn 65 if you’re collecting SSA or RRB benefits. However, you need to sign up for Part B manually.
  • If you have end-stage renal disease (ESRD, a type of kidney failure), regardless of your age, you may qualify for Medicare but you generally have to apply manually.
  • If you’re not receiving SSA or RRB benefits when you turn 65, if you want to enroll in Medicare Part B, you need to sign up for it.

You can sign up for Medicare Part B during the following enrollment periods:

  • The Initial Enrollment Period (IEP) for Part B, when you’re first eligible for Medicare. Your IEP typically starts 3 months before you turn age 65, includes your birth month, and lasts for 3 months after your birth month. That’s a total of 7 months.

    If you’re under 65 and disabled, you generally qualify for Medicare after receiving Social Security (or certain disability benefits from the Railroad Retirement Board) for 24 months. In this case, your 7-month IEP goes from the start of your 22nd month until the end of your 28th month of receiving disability benefits.

    If you sign up for Medicare Part B during your IEP, you won’t face a Part B late-enrollment penalty.

  • The General Enrollment Period (GEP), which runs from January 1 to March 31 of each year. You may enroll in Medicare Part B coverage if you are eligible. If you enroll in Part B during a GEP, it will be effective July 1 of the year in which you apply. You may have to pay a late-enrollment penalty. Your Part B premium may go up 10 percent for each 12-month period that you could have had Medicare Part B but did not sign up it.

    If you didn’t take Medicare Part B when you were first eligible because you or your spouse were working and had group health plan coverage through your employer or union, you can add Medicare Part B coverage during a Special Enrollment Period (SEP). You can sign up during the following periods under the Part B SEP:

  • While you’re still covered by the employer or union group health plan
  • During the 8 months following the month the employer or union group health plan coverage ends, or when the employment ends — whichever is first.

To add Medicare Part B, contact the Social Security Administration at 1-800-772-1213 (TTY users 1-800-325-0778), 7AM-7PM, Monday to Friday. For additional information, contact Medicare at 1-800-MEDICARE (TTY users 1-877-486-2048), 24 hours a day, 7 days a week.

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Medicare Coverage of Diabetic Services and Supplies

Medicare covers many diabetic services, if they are delivered by a doctor or other provider who accepts Medicare assignment. Medicare also covers a range of common diabetic supplies when they’re considered medically necessary.

Different parts of the Medicare program cover the various aspects of diabetic treatment.

What do Medicare Part B and Medicare Advantage plans cover?

Medicare Part B covers diabetic test supplies, screenings, and education for beneficiaries with diabetes, or for those who are at risk for diabetes.

Medicare Advantage, also called Medicare Part C, is optional private insurance. Medicare Advantage plans cover the same diabetic supplies and screenings that Medicare Part B covers. Medicare Advantage plans are required to provide at least the same amount of coverage as Original Medicare (Part A and Part B), except for hospice care.

Medicare Part B covers diabetic supplies such as:

  • Blood sugar monitors
  • Blood sugar test strips
  • Lancets and lancet devices
  • 100 test strips and lancets each month if you have diabetes and take insulin, although this can vary up to 300 strips and lancets each month
  • 100 test strips and lancets every three months if you have diabetes but do not take insulin
  • Additional test strips if your doctor says they are medically necessary, meaning they are required in your treatment
  • Glucose control solutions that check the accuracy of your equipment
  • Flu and pneumococcal shots
  • Therapeutic shoes or sole inserts, if you meet all of these conditions:
    • You have diabetes and you’re being treated under a comprehensive diabetes care plan.
    • You need therapeutic shoes or inserts because of your diabetes.
    • In one or both feet, you have any of these: poor circulation, past foot ulcers, calluses that could lead to foot ulcers, deformity, nerve damage and potential callus problems because of diabetes, or partial or complete amputation.

If you get therapeutic shoes or inserts, a podiatrist or other qualified doctor must prescribe them, and a doctor or other qualified individual like a pedorthist, orthotist, or prosthetist must fit and provide the shoes or inserts.

Medicare Part B covers diabetic services such as:

  • Up to two diabetes screenings each year if your doctor indicates you’re at risk for diabetes. After the first diabetes screening, your doctor can schedule a follow-up test.
  • Up to 10 hours of outpatient training within a 12-month period, and 2 hours of follow-up training each year after that. This training helps beneficiaries manage their diabetes.
  • Glaucoma tests every 12 months for people at risk for high glaucoma. “High risk” in this case means that at least one of these is true for you:
    • You’re diabetic.
    • Glaucoma runs in your family.
    • You’re African-American and over the age of 50.
    • You’re Hispanic and over the age of 65.
  • Foot exams every six months (unless you’ve seen a foot care professional for another reason between visits)
  • Medical nutrition therapy

Beneficiaries are responsible for a 20% coinsurance amount after the Part B deductible has been reached for diabetic equipment and supplies. Generally, you pay nothing out-of-pocket for the diabetic screening itself if Medicare covers it, but you may be responsible for a 20% coinsurance for the doctor’s visit.

What do Medicare prescription drug plans cover?

Medicare prescription drug plans cover certain diabetes-related prescription drugs. This coverage is available through private Medicare-approved insurance providers. You can get this coverage either as a stand-alone Medicare Part D prescription drug plan that works alongside your Original Medicare (Part A and Part B) insurance or by enrolling in a Medicare Advantage Prescription Drug plan which includes your Medicare coverage along with prescription drug coverage all in one plan.

Medicare prescription drug plans may cover the costs of items such as:

  • External insulin pumps (pumps worn outside the body)
  • Anti-diabetic drugs used to maintain blood sugar (glucose) levels; Insulin-related supplies, such as syringes, alcohol swabs, needles, gauze, and insulin inhalers.

Medicare prescription drug plans can vary by provider. Before enrolling in a plan, check to make sure that your diabetic needs will be met. Every plan has a formulary, which is a list of covered drugs. You can review the formulary before deciding to enroll. Joining a Medicare prescription drug plan means you are responsible for a copayment, and, depending on the plan details, a deductible may apply when you buy anti-diabetic drugs or diabetic supplies.

Getting diabetic supplies

You can go to any pharmacy or other medical equipment supplier that accepts Medicare assignment. If the supplier doesn’t accept Medicare assignment, the supplies might cost you more.

You can choose to get your diabetic supplies by mail order; if you do, see the important information below.

Note about mail-order supplies: If you’re enrolled in Original Medicare (Part A and Part B) and you mail-order these supplies, make sure you get your supplies from a Medicare contract supplier. In many parts of the U.S., Medicare has a competitive bidding program that requires you to choose from a list of approved suppliers. If you live in a competitive bidding area, and you don’t use a Medicare contract supplier, Medicare won’t cover the supplies.

To order diabetic supplies by mail, go to the medicare.gov Find a Supplier page. Start by entering your zip code and clicking Go, and then follow the steps as indicated. Again, this restriction only applies to Original Medicare; if you’re enrolled in a Medicare Advantage plan, contact your plan for a list of approved suppliers.

Be careful not to accept any supplies you didn’t order; generally Medicare won’t pay for them. If a company is sending supplies to you automatically, you’re getting misleading advertisements, or you suspect fraud relating to your diabetes supplies, call 1-800-MEDICARE (1-800-633-4227) to report it. Representatives are available by phone 24 hours a day, seven days a week. TTY users should call 1-877-486-2048.

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How are future rate increases handled?

No individuals can be singled out for cancellation or rate increase under the policy. The National Association of Realtors (NAR) is the Policyholder and if there is a rate increase all policyholders which participate with this group policy will be properly notified.

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Can MDLIVE be accessed on mobile devices?

Yes, MDLIVE can be accessed on most mobile devices with an Internet connection. Our MDLIVE Mobile App is available for download in the iTunes Store and the Google Play Store.

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How does Medicaid help people with low incomes pay medical bills?

Medicaid is a joint federal and state program that helps pay medical bills for people with low income and limited resources. Eligibility for Medicaid depends on income level and family size.

Medicaid coverage differs from state to state. In all states, Medicaid pays for basic home health care and medical equipment. Medicaid may pay for homemaker, personal care, and other services that are not covered by Medicare. There are Medicaid programs that pay some or all of Medicare’s premiums and may also pay deductibles and coinsurance for certain people who qualify for Medicare and need financial assistance.

For more information about Medicaid coverage in your state and to see whether you qualify, call your state medical assistance office.

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Who are the MDLIVE doctors?

All MDLIVE doctors are U.S. Board Certified and able to treat a wide range of patients and conditions.

Following each consultation, our members are given a survey to evaluate their doctor and appointment.

The results are analyzed and reviewed for quality assurance and used as part of our continuous improvement process. Selected doctor consultations are also reviewed by our internal medical board.

 

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Can I delay Medicare Part B enrollment without paying higher premiums?

Yes, in certain situations, you can delay your Medicare Part B enrollment without paying higher premiums (also known as a late-enrollment penalty). If you didn’t enroll in Medicare Part B when you were first eligible because you or your spouse was working and had group coverage through an employer or union, you can choose to sign up for Medicare Part B during a Special Enrollment Period (SEP) without paying a late-enrollment penalty.

You can sign up for Medicare Part B at any time that you have coverage through current or active employment. Or you can sign up for Medicare during the eight-month Special Enrollment Period that starts when your employer or union group coverage ends or you stop working (whichever happens first). If you get COBRA or retiree benefits after you stop working, keep in mind that this doesn’t count as coverage based on current employment; make sure you don’t wait until your COBRA benefits end to enroll in Medicare Part B.

Remember that if you do not enroll in Medicare Part B during your Special Enrollment Period, you’ll have to wait until the next General Enrollment Period, which occurs from January 1 to March 31 each year. You may then have to pay a late-enrollment penalty for Medicare Part B because you could have had Part B and did not enroll. If you owe a late-enrollment penalty, you’ll pay a 10% higher premium for every 12-month period that you were eligible for Medicare Part B but didn’t sign up for it. You may have to pay this higher premium for as long as you’re enrolled in Medicare.

There are a few other situations when you may be able to delay Medicare Part B without paying a late-enrollment penalty. For example, if you were volunteering overseas or if you were living out of the country when you turned 65 and weren’t eligible for Social Security benefits, you may be eligible for a Special Enrollment Period when you return to the United States. The length of your SEP will depend on your situation. If you aren’t sure if you qualify for a Special Enrollment Period, call Medicare to confirm at 1-800-633-4227 (TTY users 1-877-486-2048), 24 hours a day, seven days a week.

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Is there a claim form to fill for Drug Card America?

No. There are no claim forms or other paperwork to file. You receive your discount at the time of service and you must pay the provider the discounted amount in full at the time services are rendered.

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Does Medicare cover the shingles vaccine?

Original Medicare, Part A and Part B, does not cover the shingles vaccination. To get this covered, you must enroll in either a stand-alone Medicare Prescription Drug Plan (PDP) or a Medicare Advantage plan that includes prescription drug coverage (also known as Medicare Advantage Prescription Drug plan).

Medicare Prescription Drug Plans and Medicare Advantage plans that provide prescription drug coverage generally cover all commercially available vaccinations. These plans will cover the vaccination medication and the administration of the shot by your doctor or physician. Depending on your plan benefits, you may have to pay a copayment or coinsurance amount. Make sure to follow your plan’s guidelines for this vaccination to be covered.

You will pay the least amount of money out of pocket if you are vaccinated at a pharmacy in your drug plan’s network. If you have questions about which pharmacies are included in your plan’s network, contact your Medicare prescription drug plan or Medicare Advantage Prescription Drug plan for more information.

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How do I get my provider to be added to the network?

If your provider is not a member of the Ameritas provider network, you have several options. You can select a new provider that is in the network or discuss with your provider the possibility of becoming a member of the EyeMed network. You or your provider may contact the Provider Relations Team at 800-755-8844.

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Can a provider prescribe medication as part of an MDLIVE visit?

Yes, if the MDLIVE doctor believes medication is warranted, he or she can write a prescription for non-narcotic medications (i.e. no controlled substances), which can be sent directly to the pharmacy of your choice.* As soon your consultation is over, your prescription will be sent electronically to one of over 65,000 pharmacies to choose from. If for any reason your pharmacy is unable to receive e-prescriptions, a traditional prescription is generated for our doctors to sign and fax. All prescriptions are fully compliant and include all required information.

* Please note: Some state laws require that a doctor can only prescribe medication in certain situations and subject to certain limitations.

MDLIVE Prescription Policy

Doctors providing consultations for MDLIVE members offer prescriptions for a wide range of products that deliver direct medicinal value. These include, but are not limited to, drug classes such as antibiotics and antihistamines. Convenience prescriptions for maintenance medicines may also be obtained in cases where a member is in transition to a new insurance plan or doctor.

It is important to note that MDLIVE is not a drug fulfillment warehouse. In the event a doctor does prescribe medication, he/she will usually limit the supply to no more than thirty days. Patients with chronic illnesses should visit their primary care doctors or other specialists for extended care. MDLIVE doctors do not issue prescriptions for substances controlled by the DEA, for non-therapeutic use, and/or those which may be harmful (potential for abuse or addiction).

For a current list of DEA controlled substances, visit http://www.deadiversion.usdoj.gov/schedules/

 

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How does the Medicare PACE program help older adults?

PACE (Programs of All-inclusive Care for the Elderly) is both a Medicare and Medicaid program that provides a wide range of social and medical services at adult day health centers, inpatient facilities, and at home. The program focuses on health care for older adults within a community and provides personalized, coordinated care for their specific needs. PACE’s overall mission is to help Medicare beneficiaries preserve their independence and delay nursing-home care as long as possible.

PACE teams include primary care doctors and nurses, social workers, dietitians, personal-care attendants, and therapists. Besides giving care in the home and community, the medical staff works with PACE centers. If you enroll in PACE, you’ll get all of your Medicare benefits through the program. PACE may also cover other medically necessary services that aren’t covered by Medicare.

Services covered by PACE

PACE centers may provide services such as:

  • Primary care
  • Hospital services
  • Home health care
  • Preventive services
  • Personal care and nursing support
  • Meals
  • Physical therapy
  • Recreational therapy
  • Physical therapy
  • Occupational therapy
  • Social services
  • Dental services
  • Medical transportation (if medically necessary)
  • Prescription drugs*

*If you enroll in a PACE program, you can get your Medicare-covered prescription drugs through your PACE program instead of a Medicare Prescription Drug Plan. If you enroll in a Medicare Prescription Drug Plan, you’ll be disenrolled from PACE.

Eligibility for PACE

PACE may not be available in every state. To qualify for the program, you need to meet all of these requirements:

  • Be 55 years old or older.
  • Live in the service area of a PACE center.
  • Require a nursing home-level of care (as certified by your state).
  • Be able to safely live in the PACE community.

For more information and to apply, contact the Medicaid program in your state to see if your state offers PACE services.

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Can I drop Medicare Part B coverage and add it later if I have employer group health insurance?

Yes. If you’re a Medicare beneficiary and want to drop Medicare Part B coverage while you’re working and covered by your employer’s group health insurance, you may do so.

Medicare Part B (medical insurance) comes with a monthly premium, so some beneficiaries prefer to delay or drop Part B enrollment when they have other coverage.

If you drop Part B coverage while covered by an employer’s plan, you can sign up for Part B again during your Special Enrollment Period (SEP). You can enroll in Part B anytime that you’re working (or your spouse is working) and covered by the employer- or union-based health insurance plan.

Your SEP extends for 8 months after you or your spouse stop working, or the group coverage based on current employment ends, whichever occurs first.

An SEP lets you enroll in Medicare Part B outside of your Initial Enrollment Period. As long as you enroll in Part B during your SEP, you typically won’t have to pay a Part B late-enrollment penalty in the form of a higher premium.

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Is there a pre-existing condition exclusion for Drug Card America?

No. Remember, this is not insurance.

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Does Medicare pay for chiropractic services?

The only chiropractic service covered by Medicare is manual manipulation of the spine to correct subluxation. Subluxation of the spine is when one or more of the bones of your spine move out of position. This is covered by Medicare Part B (medical insurance) in instances where it is medically necessary and provided by a chiropractor or other qualified provider. You do not need an X-ray to prove you have a subluxation of the spine.

One way you may be able to get additional Medicare chiropractic coverage is through a Medicare Advantage (MA) plan. Some Medicare Advantage plans could provide additional chiropractic coverage benefits. Check with your Medicare Advantage plan directly to see what chiropractic services are covered. You still need to continue paying your monthly Part B premium along with any premium the plan might charge.

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How do I file a claim?

PPO providers will automatically file the claim for you. Many non-participating vision providers may file claims for you as well, however filing claims when using non-participating provider is ultimately the responsibility of the member. The claim filing process is very easy. Claim forms can be printed from our site, or generic forms that most vision providers offices have on hand can also be used.

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Is MDLIVE safe and private?

Yes, MDLIVE is safe and private. MDLIVE is compliant with HIPAA (Health Insurance Portability and Accountability Act) and will only share your information with your selected doctor and pharmacy.

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Do I need to enroll in Medicare Part B if I am a retired federal employee with an FEHB plan?

Retired federal employees are entitled to Medicare under the same rules as all other retirees.

You don’t have to take Medicare Part B coverage if you don’t want it, and your Federal Employee Health Benefits (FEHB) plan can’t require you to take it. However, there are some advantages to enrolling in Part B:

  • You have the advantage of coordination of benefits between Medicare and your FEHB plan, reducing your out-of-pocket costs.
  • If you want to join a Medicare Advantage plan, you must be enrolled in Medicare Part A and Part B.

Some HMOs waive payment of their copays and deductibles when Medicare is primary. Check your FEHB plan’s brochure for details.

  • Some services covered under Part B might not be covered or only partially covered by your FEHB plan. This includes orthopedic and prosthetic devices, durable medical equipment, home health care, and medical supplies. Check your FEHB plan brochure for details.
  • If you are enrolled in an FEHB HMO and Medicare is the primary payer, you may go outside of the plan’s network for Part B services and receive reimbursement by Medicare.
  • FEHB plan contracts are renewed yearly, so your current plan’s coverage, cost, or benefits may change next year. Your FEHB plan can also terminate their contract with the Office of Personnel Management.*

*Source:

The Federal Employees Health Benefits Program and Medicare,” United States Office of Personnel Management.

If you are or were a federal employee, you’re probably familiar with the Medicare eligibility requirement that you’re an American citizen or permanent legal resident of at least five continuous years. You are first eligible to enroll in Part B during your Initial Enrollment Period (IEP), which in most cases begins three months before you turn age 65 and ends three months after you turn age 65. (In some cases, such as if you have a disability, you may be eligible before age 65. Read more aboutMedicare eligibility.) If you do not enroll in Part B during your IEP, you may only enroll during the General Enrollment Period, which is from January 1 through March 31 of each year. Part B coverage is effective July 1, of the year of enrollment. You may have to pay higher Part B premiums if you did not enroll when you were first eligible.

The Social Security Administration handles Medicare eligibility and enrollment. To sign up for Medicare or to add Medicare Part B, call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778. You can use their automated services anytime, or speak with a live representative between 7AM to 7PM, Monday through Friday. If you visit an office in person, Social Security Administration office hours are 9AM to 4PM Monday, Tuesday, Thursday, and Friday, and 9AM to 12 noon on Wednesday. They are closed Saturday and Sunday.

The Office of Personnel Management provides useful information to retiring Federal employees on their website.

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Is my specific prescription discounted under Drug Card America?

Discounts vary and can range anywhere from 0% – 60% depending on the type of prescription, brand name, generic name and the location of the specific pharmacy.

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Does Medicare cover mental health care?

Original Medicare is made up of Part A (hospital insurance) and Part B (medical insurance), and includes certain coverage for mental health care when the care comes from a Medicare-assigned health-care provider. Learn more about this Medicare coverage below.

Medicare Part A covers hospital inpatient mental health care, including room, meals, nursing, and other related services and supplies. This care can be received in a general hospital or a psychiatric hospital.

Medicare has a lifetime limit of 190 days of inpatient care in a psychiatric hospital.

Medicare uses benefit periods for hospital coverage. A benefit period begins the day you’re admitted as a hospital inpatient, and ends when 60 days in a row have passed since you have received inpatient care.

Your Medicare Part A costs for mental health care are listed below. Please note that the deductible and coinsurance amounts may vary year to year. You pay:

  • The Medicare Part A deductible – $1,288 in 2016 (the full deductible amount is applied for each benefit period)
  • No coinsurance ($0) for days 1-60
  • $322 in 2016 coinsurance per day for days 61-90
  • $644 in 2016 coinsurance per “lifetime reserve day” after the 90th day. Lifetime reserve days are days that you remain an inpatient beyond the 90-day hospital stay that Medicare covers. Medicare pays for your covered costs, charging you a daily coinsurance amount, for up to 60 of these days in your lifetime.
  • All costs after your lifetime reserve days are used up

In addition to Medicare Part A costs, you may have some costs associated with Medicare Part B even when you’re a hospital inpatient (for example, doctor services).

Medicare Part B covers mental health services usually given outside a hospital, including visits with health professionals such as doctors, clinical psychologists, and clinical social workers. Some of the other mental health services that Medicare Part B may cover include, but aren’t limited to:

  • Annual depression screenings
  • Psychiatric evaluation
  • Certain diagnostic tests your provider orders
  • Partial hospitalization (a structured program of outpatient psychiatric services as an alternative to inpatient mental health care)
  • Individual and group psychotherapy by licensed professionals permitted by the state where therapy takes place
  • Medication management
  • Family counseling as part of your treatment

Your Medicare Part B costs for mental health care are listed below. Please note that the deductible and coinsurance amounts may vary year to year. The annual depression screenings are free if you get them from a Medicare-assigned health-care provider. For other mental health services, you pay:

  • The Medicare Part B deductible – $166 in 2016
  • 20% of the Medicare-approved amount of health-care provider services
  • A possible additional copayment or coinsurance if you receive your services as a hospital outpatient. The amount you pay depends on the service provided, but is generally 20%-40% of the Medicare-approved amount.

If you’re enrolled in a Medicare Advantage plan, you still get the same coverage listed above, and your plan might include additional benefits, such as prescription drug coverage. Offered by private Medicare-approved insurance companies, Medicare Advantage plans must provide at least the same coverage as Medicare Part A and Part B (except for hospice care, which Medicare still covers). You still continue paying your Medicare Part B premium along with any premium the Medicare Advantage plan may charge.

For more information about Medicare coverage of mental health care, see Medicare and Your Mental Health Benefits.

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How long does it take to process my claim?

Most vision claims are processed in 5 business days or less. Once processed, an Explanation of Benefits will be sent to you.

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What system requirements do I need for MDLIVE videoconferencing?

To use video conferencing you need:

  •  Windows®7, Vista, or XP
  •  A Mac running OSX 10.6 (Snow Leopard) or superior.
  •  Highspeed internet connection
  •  A webcam with at least 1.3 megapixels
  •  Microphone (most webcams already have microphone built in)

After you set up an account, you will be able to use a simple online simulation to test your configuration and check if you are ready for a virtual consultation.

 

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How much is the Medicare late-enrollment penalty?

The Medicare program may charge a late-enrollment penalty if you don’t enroll in certain Medicare programs or plans when you’re first eligible. Delaying enrollment could increase your out-of-pocket costs for your coverage. There are late-enrollment penalties for Medicare Part A, Medicare Part B, and Medicare Part D plans.

It’s important to understand the period when you’re first eligible for Medicare. This period is called your Medicare Initial Enrollment Period (IEP), and if you qualify for Medicare by age, it starts three months before you turn 65 and lasts for a total of seven months.

Original Medicare refers to Medicare Part A (hospital insurance) and Part B (medical insurance). It is the government-sponsored health care program for those who qualify by age (usually 65 and over) or disability. Medicare Part D is optional prescription drug coverage, available from private Medicare-approved insurance companies.

Note that another eligibility requirement for Medicare is American citizenship or permanent legal residence for at least five years in a row.

Medicare Part A

Most Medicare beneficiaries get Medicare Part A premium-free. You won’t be charged a premium forPart A if you or your spouse worked at least 10 years (40 quarters) while paying Medicare taxes. And you’re automatically enrolled in Medicare Part A if you’re already collecting Social Security or Railroad Retirement benefits when you turn 65 or qualify through disability.

If you don’t qualify for premium-free Medicare Part A, and you’re not automatically enrolled, then you may be required to pay a 10% higher monthly premium if you do not enroll when you are first eligible. You will have to pay this higher premium for twice the number of years that you could have had Part A coverage, but did not enroll. The Part A premium is $411 in 2016 (without the penalty).

For example, if you delayed enrollment in Medicare Part A for one year after your IEP was over, you could pay a 10% higher monthly premium for two years.

Medicare Part B

Medicare Part B may also have a late-enrollment penalty if you don’t sign up when first eligible, depending on your situation. Your monthly premium may go up 10% for each full 12-month period that you went without Part B coverage after your IEP ended. You may have to pay this enrollment penalty for the remainder of the time that you are enrolled in Medicare.

For example, suppose your IEP ended August 6, 2014, and you delayed Medicare Part B enrollment until the Medicare General Enrollment Period (January 1-March 31) in 2016. This would only include one full 12-month period of delay, so in this case you’d pay a 10% penalty on top of your Medicare Part B premium — but you’d pay this penalty for as long as you’re enrolled in Medicare.

Some people choose to defer enrollment in Medicare Part B — such as beneficiaries who are still working and covered by an employer’s group plan. This is an example of a situation that would qualify you for a special enrollment period for Part B, and you wouldn’t have to pay the late-enrollment penalty.

Medicare Part D

You may have to pay a higher monthly premium for your Medicare Part D Prescription Drug Plan if you go 63 or more consecutive days without creditable prescription drug coverage after your IEP. Creditable prescription drug coverage is coverage that is expected to pay at least as much as standard Medicare prescription drug coverage, on average. Currently, Medicare calculates the late-enrollment penalty by multiplying the 1% penalty rate of the “national base beneficiary premium” $34.10 in 2016 by the number of full, uncovered months you were eligible to enroll in a Medicare Prescription Drug Plan but did not (assuming you didn’t have other creditable prescription drug coverage). The final amount is rounded to the nearest $0.10 and added to your monthly premium.

For example, suppose you signed up for a Medicare Part D Prescription Drug Plan in 2016, eight months after your IEP ended. One percent of $34.10 is $0.341 x 8 months =$ 2.73 (rounded down to $2.70). So, $2.70 would be added to your monthly Medicare Part D premium.

The “national base beneficiary premium” may go up each year, so the penalty amount may also go up every year. In addition to your premium each month, you may have to pay this penalty for as long as you have a Medicare Prescription Drug Plan.

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How many drugs are covered under the Drug Card America prescription discount card?

All FDA-approved prescription medications are eligible for a discount. However, discounts are based on several criteria such as; type of prescription, brand name, generic name and the location of the specific pharmacy. Be sure to ask your pharmacist if your specific drug is discounted under this program.

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Can a home health agency (HHA) decline me as a patient?

Yes, the agency may decline you if it doesn’t have the ability or resources to meet your medical needs. A Medicare-certified home health agency (HHA) is not required to take you as a patient simply because your doctor has prescribed care for you and you qualify for Medicare-covered home care.

While most home health agencies will take all Medicare beneficiaries, agencies have the ability to choose the patients they accept. A home health agency may decline a patient if it doesn’t believe it can meet the individual’s health needs, as long as it does not treat that person differently from other patients. For example, if a home health agency refuses to accept you as a patient because of a medical condition you have, the organization cannot then accept other patients who have the same health condition.

If you are in a Medicare health plan, such as a Medicare Advantage plan, your plan may only pay for you to get care from home health agencies that are within the plan’s network. Check with your specific Medicare plan for more information on rules regarding providers.

A home health agency can also limit the kinds of services it provides and the types of conditions it will cover. If you need services that the home health agency does not provide, the agency can choose to reject you as a patient as long as its policies are consistent for all patients. For example, an HHA can decide it will not treat patients with dementia because it doesn’t have the resources or trained staff to do so.

In addition, an HHA can refuse to take you as a patient if it does not believe that it can ensure your safety. For example, if you need round-the-clock personal care in addition to services the home health agency provides, but you are opting to go without that care, the agency could find your situation unsafe and not accept you as a patient. Sometimes, the home health agency may decline to take you as a patient because it does not have the staff available to take on new patients.

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Where are claims submitted?

Claims can be sent to:
Ameritas Group Vision Claims
P.O. Box 82520
Lincoln, NE 68501

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How does Medicare work?

Medicare is a federal health insurance program that provides benefits to American citizens and permanent legal residents (of at least five continuous years) aged 65 and older, or who have a qualifying disability or illness. Most people are automatically enrolled into Original Medicare, Part A and Part B, when they become eligible; however, some people need to manually enroll in Medicare. Medicare Part A is hospital insurance; Medicare Part B is medical insurance.

You may want to take a look at these Medicare plan options.

  • Medicare Advantage (Medicare Part C) gives you a way to get your Original Medicare coverage through a private, Medicare-approved insurance company instead of directly through the government. Medicare Advantage plans provide all your Medicare Part A and Part B benefits other than hospice care, which Part A still covers. But many Medicare Advantage plans include extra benefits, such as routine dental and vision services. And most Medicare Advantage plans include prescription drug coverage, letting you get all your Medicare benefits through a single plan. You still need to continue paying your Medicare Part B monthly premium, besides any premium the Medicare Advantage plan might charge.
  • If you stay with Original Medicare, be aware that prescription drugs aren’t covered in most situations. Medicare Part D offers prescription drug coverage through private, Medicare-approved insurance companies. You may want to consider adding a stand-alone Medicare Prescription Drug Plan.
  • If you decide to stay with Original Medicare, another option you may have is to sign up for aMedicare Supplement (Medigap) plan to help pay for Original Medicare’s out-of-pocket costs. Different Medigap plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles.

Availability and costs of Medicare plan options may vary from one insurance company to another, and from one geographic area to another.

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I have a question that isn’t listed here. Can you help me?

Don’t see your question? Don’t worry. Just call us at 1-888-632-2738. We have highly trained health service specialists standing by to take your call, 24/7/365.

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I have Medicare now; do I need to do anything else?

If you’ve recently enrolled in Original Medicare, congratulations! Now is a good time to learn about the different parts of Medicare, so you can understand what your benefits include and decide if you want to sign up for additional coverage.

It’s important to understand that Original Medicare, Part A and Part B, doesn’t include most prescription drug coverage. If you’d like Medicare prescription drug coverage, you can get it from a private health insurance company that contracts with Medicare.

Besides getting prescription drug coverage, you may have other options when you’re first eligible for Medicare.

Here’s a quick rundown of your Medicare coverage options beyond Original Medicare:

  • You can have Original Medicare and enroll in a stand-alone Medicare Part D Prescription Drug Plan.
  • You can have Original Medicare and purchase a Medigap (Medicare Supplement) plan. There are 10 standardized Medigap policies in most states, and they cover varying amounts of your Medicare Part A and Part B costs (such as coinsurance and deductibles), depending on the Medigap policy.
  • Or you can enroll in a Medicare Advantage plan. With a Medicare Advantage plan, you get your Medicare Part A and Part B benefits through a private, Medicare-approved insurance company. Many Medicare Advantage plans include prescription drug coverage, so you can get all your Medicare health and drug benefits in a single plan.

You typically continue paying your monthly Medicare Part B premium with any of these options.

If you’re content with Original Medicare, Part A and Part B, and you don’t need prescription drug coverage now, and you don’t want to add Medicare Supplement insurance–then you don’t have to make any coverage changes now. Do be aware that if you go without creditable prescription drug coverage for more than 63 days, you might have to pay a late-enrollment penalty if you decide to sign up for a Medicare drug plan later. Creditable prescription drug coverage is other coverage (such as a state pharmaceutical assistance prescription drug program, some employer group coverage, etc.) that provides prescription drug coverage that is as good as a standard Medicare prescription drug plan. If you have other prescription drug coverage, the company you get coverage from is required to inform you if it is considered creditable.

You’ll still have other chances to make changes to your Medicare coverage later on. For information about enrollment periods, see Medicare Enrollment: How and When to Enroll in Medicare.

No matter how you decide to get your Medicare coverage, keep in mind that costs and benefits may change from one year to the next, so it’s a good idea to review your coverage annually to make sure it’s still meeting your needs. Premiums, cost sharing expenses, and specific benefits are all subject to change, whether you’re enrolled in Original Medicare, a Medicare prescription drug plan, or a Medicare Advantage plan.

If you’re enrolled in a Medicare Advantage plan or a Medicare Prescription Drug Plan, it’s a good idea to carefully review your plan’s Annual Notice of Change and Evidence of Coverage notices every fall to keep up with any coverage or cost changes. You can make coverage changes during the Annual Election Period (from October 15 to December 7).

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What is a brand name drug?

A brand name drug is approved by the Food and Drug Administration (FDA), and is supplied by one company (the pharmaceutical manufacturer). The drug is protected by a patent and is marketed under the manufacturer’s brand name.

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How do I qualify (eligible) for this plan?

 

  • be over age 18, unless a dependent of a member – There is no age limit to qualify for these plans
  • be an NAR member
  • Association Executive members and their staff

 

 

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What is a Comprehensive Outpatient Rehabilitation Facility (CORF)?

CORF stands for Comprehensive Outpatient Rehabilitation Facility, which is a facility that provides outpatient services such as physical therapy, rehabilitation, physicians’ services, and social or psychological services.

Medicare provides limited coverage in CORFs. After you pay your Medicare Part B deductible amount, Medicare Part B generally covers 80% of your costs in a CORF, and you pay the remaining 20%.

However, there is a limit, called a cap, on how much Medicare will cover in one year. This cap may vary from year to year.

In some cases, you might qualify for an exception on the therapy cap limit. Your health-care provider must provide documentation that your need for further therapy is reasonable and medically necessary. For more information, contact your State Health Insurance Assistance Program (SHIP). To get the phone number for your state, visit shiptacenter.org, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Medicare representatives are available 24 hours a day, seven days a week.

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How do I make changes to my vision insurance plan?

For customer service, billing, and plan change questions please contact our customer service department at 1-800-279-2290.

Our office hours are M-T 7:00 AM to 7:00 PM (5:00 PM on Friday) central/standard time.

 

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Do I need Medicare Part A or Part B if I am still working?

This depends on your situation. If you’ve worked at least 10 years (40 quarters) under Medicare-covered employment and paid Medicare taxes during that time, you qualify for premium-free Medicare Part A and will be automatically enrolled at age 65 even if you’re still working. If your spouse has enough employment quarters, you can also qualify for premium-free Medicare Part A based on his or her work history.

Another Medicare eligibility requirement is that you need to be an American citizen or permanent legal resident of at least five continuous years.

If you don’t have enough work history to get Medicare Part A without paying a premium, you can decide to delay enrollment if you already have health coverage through an employer or union (or through your own work or your spouse’s employer). Medicare Part B always comes with a monthly premium, so you may similarly choose to delay your Part B enrollment if you or your spouse are still working and have employer-based group coverage.

Remember, if you don’t sign up for Medicare when you’re first eligible and don’t have other coverage based on current employment, you could have to pay a late-enrollment penalty later when you do enroll. The late-enrollment penalty applies to Medicare Part B (and Part A, if you have to pay a premium for it).

One factor to consider is that even if you have health coverage through your employer or union, Medicare may help pay for some of the costs not covered by your group health plan. For example, enrolling in Medicare may be useful if you work for a small company (less than 20 employees) because Medicare could be the primary payer before your group health insurance. You may want to consult with your employer or union benefits administrator for specifics on how your health coverage and costs may compare with Medicare.

If you do decide to wait until your group coverage ends to enroll in Medicare Part A and/or Part B, you’ll have an 8-month Special Enrollment Period to sign up for Medicare that starts once you stop working or your group coverage ends (whichever happens first). You can also enroll in Medicare at any time that you are still working and have employer-based coverage.

If you choose COBRA after you stop working, do not wait until your COBRA coverage ends to sign up for Medicare. If you delay enrolling in Medicare Part A and/or Part B after your Special Enrollment Period ends, you’ll have to wait until the next General Enrollment Period (January 1 to March 31 every year) to enroll, and you may have to pay a late-enrollment penalty.

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How often can I change Medicare plans?

As your health-care needs evolve over time, you may need to change Medicare plans in order to receive the coverage that best fits your health requirements. Changing Medicare plans can be relatively easy, if you understand when and how often you can switch from one Medicare plan to another.

Annual Election Period

If you want to change Medicare Advantage or Medicare Part D Prescription Drug Plans , the best time to do so is during the Annual Election Period (also called Open Enrollment Period for Medicare Advantage and Medicare prescription drug coverage), which runs from October 15 to December 7 each year. During that period, you can:

  • Change from Original Medicare, Part A and Part B, to a Medicare Advantage plan.
  • Change from a Medicare Advantage plan back to Original Medicare, Part A and Part B.
  • Switch from one Medicare Advantage plan to another.
  • Switch from a Medicare Advantage plan that doesn’t offer drug coverage to a Medicare Advantage plan that does.
  • Switch from a Medicare Advantage plan that offers drug coverage to a Medicare Advantage plan that doesn’t.
  • Switch from one Medicare Prescription Drug Plan (Part D) to another.

When you change Medicare plans during the Annual Election Period, your new coverage begins on January 1 of the following year.

Medicare Advantage Disenrollment Period

If you’re enrolled in Medicare Advantage and want to switch back to Original Medicare, Part A and Part B, you can do so during the Medicare Advantage Disenrollment Period, which runs from January 1 to February 14 each year. You will also have until February 14 to join a Medicare Prescription Drug Plan (Part D), and your coverage will go into effect the first day of the month after your new plan gets your enrollment form.

Special Election Period

Medicare has certain provisions to help you deal with unexpected happenings. If you go through certain special circumstances, you may be able to change Medicare plans during Special Election Periods. These events may include, but aren’t limited to: Moving to a new address; losing your current coverage; qualifying for other coverage such as Medicaid, Employer Group Coverage and State Pharmaceutical Assistance Program; or becoming qualified for Extra Help to pay for Medicare Part D coverage through the Social Security Administration. The dates and types of changes you can make vary according to the Special Election Period.

How to change Medicare plans

Be aware that if you want to disenroll from a Medicare Advantage plan and don’t want to enroll in another Medicare Advantage plan, you have to notify your plan in writing. However, if you want to change from one Medicare Advantage plan to another or from one Medicare prescription drug plan to another, all you have to do is join the new plan, and you will automatically be disenrolled from the old one.

Also understand that you can generally only change Medicare plans during the Medicare Advantage Disenrollment Period, Annual Election Period, or a Special Election Period (whichever applies).

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What is a generic drug?

When a drug patent expires other companies may produce a generic version of the brand name drug. A generic medication, also approved by the FDA, is basically a copy of the brand name drug and is marketed under its chemical name. A generic drug may have a different color or shape than its brand name counterpart, but it must have the same active ingredients, strength, and dosage form (i.e., pill, liquid, or injection), and provide the same effectiveness and safety as its brand name counterpart.

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The Social Security Act created a system of payment for the operating costs associated with Medicare Part A hospital inpatient stays. This system is based on set rates and is referred to as the Inpatient Prospective Payment System (IPPS). As a part of this system, each case is categorized into a Medicare Severity — Diagnosis Related Group (MS-DRG).

Patients who have similar clinical characteristics and similar treatment costs are assigned to an MS-DRG. The MS-DRG is linked to a fixed payment amount based on the average treatment cost of patients in the group. Patients can be assigned to an MS-DRG based on their diagnosis, surgical procedures, age, and other information. Hospitals provide this information on their Medicare claim, and Medicare uses this information to decide how much the hospitals should be paid.

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What happens if my expiration date changes on my credit card I have been using?

If any billing changes need to be made, you will need to contact the customer service dept by phone at 1-800-279-2290.

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Which doctors accept Medicare assignment?

Not every doctor may accept Medicare assignment (a payment agreement). Doctors who have been approved to accept Medicare assignment can fall into any of the following categories:

  • Participating doctors accept Medicare assignment, meaning that they accept the Medicare-approved amount as payment for their services. These doctors charge the Medicare program 80% and the beneficiary 20% of the cost of the benefit.
  • Non-participating doctors can choose to either accept or not accept Medicare assignment. If the doctor does not accept Medicare assignment, you might have to pay a 15% additional charge above the cost of the service, known as a Medicare excess charge. You would then be responsible for up to 35% of the reduced Medicare-approved amount instead of 20%.
  • Doctors who have opted out of Medicare may charge you whatever they see fit for services and supplies, and you are responsible for the full cost of these benefits.

To find a participating doctor in your area, you may use the Medicare.gov Physician Compare tool. This tool will help you find an approved Medicare doctor based on medical specialty, geographical area, or doctor’s name. In addition to finding Medicare-approved physicians, this tool provides information about each doctor, along with maps and directions to help you find the doctor’s office.

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Is Medicare Part D optional?

Whether you qualify for Medicare by turning 65 years of age, through disability or by having a condition like Lou Gehrig’s disease, you may have the option to enroll into Medicare Part A and/or Part B. You also need to be an American citizen or permanent legal resident of at least five continuous years to qualify for Medicare.

Depending on your work history and how you qualify, you may be automatically enrolled or need to manually enroll. But one thing people often wonder about is how they obtain Medicare Part D, which is prescription drug coverage and doesn’t automatically come with Original Medicare.

Medicare Part D benefits are available from either a stand-alone Medicare Prescription Drug Plan or a Medicare Advantage Prescription Drug plan, which combines Original Medicare (Part A and Part B) benefits with prescription drug coverage. Both types of plans are administered by private insurance companies, and specific benefits and prices vary depending on the service area you live in.

Is Medicare Part D optional? You’re not required to enroll into a Medicare Part D Prescription Drug Plan. However, if you go without creditable prescription drug coverage for 63 or more days in a row, you may have to pay a late-enrollment penalty if you enroll into a Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan later.

Read below to find out more about what kinds of coverage can help you avoid this penalty, when you can enroll in a Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan, and other information regarding the late-enrollment penalty.

What is creditable prescription drug coverage?

If you have health insurance in addition to Medicare, this might include creditable drug coverage. The plan must tell you each year whether or not the prescription drug coverage is creditable, meaning it covers at least as much, on average, as Medicare’s standard prescription drug coverage does. Some common examples of creditable coverage include (but are not limited to) health insurance from:

  • Employer group coverage or union plans
  • United States Department of Veterans Affairs (VA)
  • TRICARE
  • Indian Health Service (IHS)

You can continue to use this prescription drug coverage alongside your Medicare benefits without penalty, as long as it’s creditable.

When can you enroll in Medicare Part D?

To enroll into a Medicare Part D Prescription Drug Plan, you need to have either Medicare Part A or Part B, and you have to live in the service area of the plan you choose. If you’re eligible for Medicare because of age, your seven-month Initial Enrollment Period for Part D usually takes place at the same time as your Initial Enrollment Period for Part B, starting three months before your 65th birthday, including your birthday month, and ending three months later. If you qualify for Medicare through disability, you’ll get a subsequent Initial Enrollment Period for Part D when you turn 65 years of age.

The Medicare Part D late-enrollment penalty may apply if you enroll any time after your Initial Enrollment Period for Part D and go without creditable prescription drug coverage for more than 63 days in a row. If you don’t enroll in Medicare Part D when you’re first eligible, your next opportunity will be during the Annual Election Period that occurs from October 15 to December 7 of every year. During this time, you can enroll into a stand-alone Medicare Prescription Drug Plan if you have Original Medicare or get drug coverage through a Medicare Advantage Prescription Drug plan. You can also use this period to switch plans or disenroll from your plan.

Another time you may be able to make changes to your Medicare Part D coverage is during the Medicare Advantage Disenrollment Period, which runs from January 1 to February 14 annually. If you disenroll from your Medicare Advantage plan and return to Original Medicare, you can also use this period to enroll into a stand-alone Medicare Prescription Drug Plan, since Original Medicare doesn’t include most prescription drug benefits. You can’t use the Medicare Advantage Disenrollment Period to make other types of Medicare plan changes.

Outside of these periods, you can’t make changes to your Medicare Part D coverage unless you qualify for a Special Election Period. Certain situations allow you to make changes outside of the regular periods and may include, but isn’t limited to, moving out of your plan’s service area, losing Medicaid eligibility, or moving into a nursing home.

What is the Medicare Part D late-enrollment penalty?

If you’ve gone 63 consecutive days without creditable prescription drug coverage, either because you didn’t enroll when you were first eligible or because you lost your creditable coverage and didn’t get new coverage in time, then you may have to pay a late-enrollment penalty when you do enroll into Medicare Part D.

The Medicare Part D late-enrollment penalty is added to the premium of the Part D Prescription Drug Plan you enroll into. Your Medicare Prescription Drug Plan determines this penalty by first calculating the number of uncovered months you were eligible for Medicare Part D, but didn’t enroll into a Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan. Your Medicare Prescription Drug Plan will then ask you if you had creditable prescription drug coverage during this time. If you didn’t have creditable drug coverage for 63 days in a row, the Medicare Prescription Drug Plan must report the number of uncovered months to Medicare.

For example, let’s say you disenrolled from your Medicare Prescription Drug Plan effective February 28, 2014, then decided to enroll into another Medicare Prescription Drug Plan during the Annual Election Period, for an effective date of January 1, 2016. This means you didn’t have creditable drug coverage from March 2014 through December 2014, which adds up to 10 uncovered months.

Currently, the late-enrollment penalty is calculated by multiplying 1% of the “national base beneficiary premium” ($34.10 in 2016) times the number of full, uncovered months that you were eligible but didn’t join a Medicare drug plan and went without other creditable prescription drug coverage . This number is then rounded to the nearest $.10 and added to your Medicare Prescription Drug Plan monthly premium cost. The “national base beneficiary premium” may increase each year, so the total of your late-enrollment penalty can also increase each year.

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Are generic drugs as safe as brand name drugs?

Yes. The FDA requires that all drugs be safe and effective and that their benefits outweigh their risks. Since generics use the same active ingredients and are shown to work the same way in the body, they have the same risks and benefits as their brand name counterparts.

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Who is an eligible dependent?

a. an Insured’s spouse.

b. each unmarried child less than 26 years of age, (less than 30 years of age for discharged military dependents), for whom the Insured or the insured’s spouse, is legally responsible, including:

  1. natural born children;
  2. adopted children, eligible from the date of placement for adoption;
  3. a grandchild that is a dependent of, and under interim court-ordered custody of the Insured;
  4. children covered under a Qualified Medical Child Support Order as defined by applicable Federal and State laws.

c. each unmarried child age 26 or older who:

  1. because of a handicapped condition that occurred before attainment of the limiting age, is incapable of self-sustaining employment; and
  2. is dependent on his or her parents or other care providers for lifetime care and supervision.

 

“Dependent on other care providers” is defined as requiring a Community Integrated Living Arrangement, group, home, supervised apartment, or other residential services licensed or certified by the Department of Mental Health and Development Disabilities, the Department of Public Health, or the Department of Public Aid.

Coverage of such child will not cease if proof of dependency and disability is given within 31 days of attaining the limiting age and subsequently as may be required by us but not more frequently than annually after the initial two-year period following the child’s attaining the limiting age. Any costs for providing continuing proof will be at our expense.

 

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Is transportation to my doctor included in my Medicare plan?

Medicare generally does not cover transportation to get routine health care. However, it may cover non-emergency ambulance transportation to and from a health-care provider if you need to have a health condition diagnosed or treated and other forms of transportation could endanger your health. Your doctor must provide a written order verifying that ambulance transportation is medically necessary because of your health condition.

If you use an ambulance company based in New Jersey, Pennsylvania, or South Carolina, you may be affected by prior authorization rules if you need non-emergency, scheduled, medically necessary ambulance services 1) three or more times over a 10-day period or 2) at least once a week for three or more weeks. To find out if these rules affect you, contact Medicare at 1-800-633-4227 (TTY users, dial 1-877-486-2048), 24 hours a day, seven days a week.

For beneficiaries who do not qualify for non-emergency ambulance transportation, there may be transportation services available in their immediate area through local organizations. For instance, your local Area Agency on Aging (AAA) may be able to help you find transportation to and from your health-care provider. To locate a State and/or Area Agency on Aging, you can use the SUA/AAA Finder on the organization’s website.

If you are eligible for Medicaid or Program of All-Inclusive Care for the Elderly (PACE), these organizations may also provide transportation for routine medical care. Visit www.Medicaid.gov orwww.Pace4you.org for more information.

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What happens if my payment was declined?

You will be notified by phone or email and you will also receive a letter in the mail. Your policy will be in danger of lapsing.

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What is the “Welcome to Medicare” physical exam?

The “Welcome to Medicare” physical exam is a one-time, preventive physical exam Medicare covers within the first 12 months that you have Medicare Part B. The visit will include a thorough review of your health, along with education and counseling about the preventive services you need, like certain screenings, shots, and referrals for other care.

This visit is a great way to get up-to-date on important screenings and shots and to talk with your doctor about your family history and how to stay healthy. During the “Welcome to Medicare” visit, your doctor will record your medical history and check your vision, blood pressure, and weight and height to measure your body mass index (BMI). Body mass index is a measure of body fat that applies to both adult men and women.

Your doctor will check that you are up-to-date with preventive screenings and services, such as cancer screenings and immunizations. Further tests may be ordered, if necessary, depending on your general health and medical history. Your doctor will also give you advice to help you prevent disease, improve your health, and stay well. You will get a written plan (such as a checklist) when you leave, letting you know which screenings and other preventive services you should get in the future.

Your doctor will also talk with you about creating advance directives. Advance directives are legal documents that explain in writing what kind of health care you would want if you were too ill to speak and/or make decisions for yourself. Talking to your family, friends, and health care providers about your wishes is important, but these legal documents help ensure your wishes are followed.

When do I get my “Welcome to Medicare” exam?

Once you enroll into Medicare Part B, schedule your “Welcome to Medicare” preventative visit right away. Medicare will only cover this physical exam if it occurs within the first 12 months from when you enroll into Medicare Part B.

If you’ve had Medicare Part B for over 12 months, you can get a yearly “Wellness” visit instead. This visit is also covered and can help you and your doctor develop a personalized health plan.

How much does the exam cost?

You pay nothing for your “Welcome to Medicare” preventative visit or the yearly “Wellness” visits if the doctor or health care provider accepts assignment. If you have additional tests or receive other services during this visit that aren’t covered under these preventative benefits, you may have to pay coinsurance and the Medicare Part B deductible may apply.

What should I bring with me to the exam?

You should bring the following things with you when you go to your “Welcome to Medicare” visit:

  • Medical records, including immunization records.
  • A list of prescription drugs, as well as over-the-counter drugs and supplements that you currently take, how often you take them, and why.
  • Family health history. Try to learn as much as you can about your family’s health history before your appointment.
  • Any information you can give your doctor to help determine if you are at risk for certain diseases.

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What’s the difference between Medicare Advantage and Medicare Supplement plans?

There are different ways that you can receive your Medicare coverage, or add onto that coverage. Medicare Advantage and Medicare Supplement insurance are options that may sound similar, but they’re quite different. They do have one main thing in common: they’re both offered by private insurance companies.

Original Medicare, Part A and Part B, is a government health insurance program for those who qualify by age or disability. Part A is hospital insurance, and Part B is medical insurance. There are some out-of-pocket costs associated with Original Medicare, such as copayments, coinsurance, and deductibles. To help with those costs, if you’re enrolled in Original Medicare, you can purchase a Medicare Supplement (Medigap) plan.

Medicare Advantage plans offer an alternative way to receive your Medicare benefits through a private, Medicare-approved insurance company. They must include all your Medicare Part A and Part B coverage (except hospice care, which is covered under Medicare Part A), but may offer additional benefits not included in Original Medicare.

You generally cannot enroll in both a Medicare Advantage plan and a Medigap plan at the same time.

Medicare Advantage plans

If you have a Medicare Advantage plan, you’re still enrolled in the Medicare program; in fact, you must sign up for Medicare Part A and Part B to be eligible for a Medicare Advantage plan. The Medicare Advantage plan administers your benefits to you. Depending on the plan, Medicare Advantage can offer additional benefits beyond your Part A and Part B benefits, such as routine dental, vision, and hearing services, and even prescription drug coverage.

There are many different types of Medicare Advantage plans, described below:

  • Health Maintenance Organizations (HMOs) require you to use health-care providers in a designated plan network and may require referrals from a primary care physician in order to see a specialist.
  • Preferred Provider Organizations (PPOs) recommend the use of “preferred” health-care providers in an established network, and these plans are likely to cover more of your medical costs if you stay inside that network. You don’t need a referral to see a specialist.
  • Private Fee-for-Service (PFFS) plans determine how much they will pay health-care providers, and how much the beneficiary is responsible to cover out-of-pocket.
  • Medical Savings Account (MSA) plans deposit money into a “health-care checking account” that you use to pay for health-care costs before the deductible is met.
  • Special Needs Plans (SNP) are tailored health insurance plans designed for beneficiaries with certain health conditions.

If you decide to sign up for a Medicare Advantage plan, you may want to shop around, because costs and coverage details are likely to vary. Our obligation-free eHealthMedicare plan finder tool on this page lets you see all available Medicare Advantage options in your area, including a list of coverage details once you click on the plan of interest.

Some of the costs associated with Medicare Advantage might include a monthly premium (not counting your Part B premium, which you must continue to pay as well), annual deductible, coinsurance, and copayments.

To be eligible to enroll in a Medicare Advantage plan, you must be enrolled in Original Medicare, reside in the plan’s service area, and (in most cases) not have end-stage renal disease (ESRD).

Medicare Supplement plans

Medicare Supplement insurance, also known as Medigap or MedSup, is also sold through private insurance companies, but it is not comprehensive medical coverage. Instead, Medigap functions as supplemental coverage to Original Medicare. Current Medigap plans don’t include prescription drug coverage.

Medigap plans may cover costs like Medicare coinsurance and copayments, deductibles, and emergency medical care while traveling outside of the United States. There are 10 standardized plan types in 47 states, each given a lettered designation (Plan G, for example). Plans of the same letter offer the same benefits regardless of where you purchase your plan. Massachusetts, Minnesota, and Wisconsin offer their own standardized Medigap plans.

The standardized Medigap plans each cover certain Medicare out-of-pocket costs to at least some degree. Every Medigap plan covers up to one year of Medicare Part A coinsurance and hospital costs after Medicare benefits are used up. But, for example, Medigap Plan G plans don’t cover your Medicare Part B deductible, while Medigap Plan C plans do. So, if you’d like to enroll in a Medicare Supplement plan, you might want to compare the Medigap policies carefully.

While benefits are standardized, the costs are not, meaning they could fluctuate depending on the insurance company offering the plan and location. That is, while Medigap Plan G includes the same coverage no matter where you buy it, the premium for this plan can vary. Also, not every standardized lettered plan is offered in every state.

If you decide to sign up for a Medigap policy, a good time to do so is during the Medigap Open Enrollment Period, a six-month period that typically starts the month you turn 65 and have Medicare Part B. If you enroll in a Medigap plan during this period, you can’t be turned down or charged more because of any health conditions. But if you apply for a Medigap plan later on, you may be subject to medical underwriting; your acceptance into a plan isn’t guaranteed.

No matter whether you enroll in a Medigap policy or a Medicare Advantage plan, you must continue paying your Part B premium.

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Can I ask the pharmacy to substitute a generic drug for the drug prescribed by my doctor?

Each state has a law that allows pharmacists to substitute less expensive generic drugs for many brand names. However, if your doctor specifies that a brand name must be dispensed, then the pharmacist may not substitute the generic. Sometimes an acceptable generic is available that your doctor may not be aware of. In this case, your pharmacist may be able to consult with your doctor to suggest an effective medication that costs less.

 

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When should I enroll my dependents?

Eligible dependents should be enrolled at the time of application. If you would like to add dependents at another time, you may but they will have their own waiting period (6 months for major services and 12 months on ortho) to satisfy. Dependents enrolled at a later date will take effect at the following month renewal date.

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Will Medicare pay for ambulance services?

Medicare pays for limited ambulance services. If you go to a hospital or skilled nursing facility (SNF), ambulance services are covered only if any other transportation could be a danger to your life or health. If the care you need is not available locally, Medicare helps pay for necessary ambulance transportation to the closest facility outside your local area that can provide the care you need.

If you choose to go to another facility farther away, Medicare payment is determined based on how much it would cost to go to the closest facility. All ambulance suppliers must accept assignment. Medicare does not pay for ambulance transportation to a doctor’s office. Air ambulance is paid only in emergency situations, such as when you can’t be easily reached by land, or if heavy traffic could prevent you from getting crucial care quickly. If you could have been transported by land ambulance without serious danger to your life or health, Medicare pays only the land ambulance rate and you are responsible for the difference.

If you have end-stage renal disease (ESRD), in some cases Medicare may cover ambulance services to and from a dialysis facility. If you have questions about Medicare coverage of ambulance transportation, contact Medicare at 1-800-MEDICARE (1-800-633-4227; TTY users 1-877-486-2048), 24 hours a day, 7 days a week.

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How long do I have to make a missed payment?

Your policy gives you 31 days from the due date to post a new payment. If a payment has not been posted within that time, your policy will terminate due to nonpayment. Your insurance coverage dates will reflect the approved payments made.

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How do I change my address through Social Security?

If you get Social Security benefits, you can change your Medicare address online at the Social Security website. If you change your address online, you will be asked a series of questions to verify your identity. Your answers must match the information Social Security has in its records. You can only change your address online if you have established a permanent password, which can be created by visiting My Social Security.

If you do not want to answer the questions online or you do not have a permanent password, you cannot submit a change of address online. Instead, you can call the Social Security Administration at 1-800-772-1213 (TTY 1-800-325-0778), Monday through Friday, from 7AM to 7PM and speak to one of their representatives or visit your local Social Security office.

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Am I covered by Medicare if I travel outside of the United States?

If you are a beneficiary of Original Medicare, Part A and Part B, then you are free to travel anywhere in the U.S. without fear of losing your Medicare coverage. If you travel outside of the country, however, your Part A and Part B coverage options are much more limited.

For example, Medicare will provide emergency coverage in Canada if you are traveling a direct route, and without unreasonable delay, between Alaska and another U.S. state, and the closest hospital that can treat you is in Canada. Medicare will also cover you while on a cruise ship if you need to receive care while the ship is in U.S. waters or port (or within six hours of arrival or departure from a U.S. port).

While in a foreign country, such as Canada or Mexico, Medicare could potentially cover non-emergency inpatient services if foreign treatment is closer to your residence than the nearest U.S.-based hospital. Medicare may cover medically necessary ambulance services to reach the foreign hospital, but only if you are admitted for a medically necessary covered inpatient hospital service.

In these situations, you pay 20% of the Medicare-approved amount and also the Part B deductible.

Traveling with Medicare Advantage

If you receive your Medicare coverage through a Medicare Advantage (MA) plan, instead of Original Medicare, you may be required you stay within the plan service network to receive routine care when traveling inside the U.S. or you could be subject to pay higher costs . If this is the case, you would still be covered for emergency and urgent care as needed. Some MA plans are more flexible than others and may let you see health care providers outside of your network to obtain routine care. Remember, depending on the particulars of your Medicare Advantage plan, however, you could have to pay a higher amount to receive non-emergency care.

Medigap coverage outside the U.S.

As another option for foreign travel coverage, you may want to purchase a Medicare Supplement plan, also known as Medigap or MedSup, to receive coverage while traveling outside of the U.S. Specifically, Plans C, D, F, G, M, and N provide some degree of foreign travel coverage up to plan limits. Some Medicare Advantage plans provide coverage for travel abroad also. Please note that Medigap plans are designed to supplement Original Medicare benefits and cannot be used in combination with a Medicare Advantage plan.

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What is a Medicare HMO? What are the differences between HMOs and PPOs?

There are four main types of Medicare Advantage plans, but Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans are the most common types. Here is a comparison of the two varieties:

  • HMO plans require that beneficiaries see health-care providers, doctors, and hospitals within the plan’s network except in urgent and emergency situations. In some plans, known as HMO Point-of-Service (HMO-POS) plans, beneficiaries may be able to go out-of-network for certain services, but may have to pay a higher cost.
  • PPO plans do not require that beneficiaries use in-network providers and do not require a referral to see a specialist.
  • HMO plans may require that beneficiaries choose a primary care physician.
  • PPO plans do not require that beneficiaries choose a primary care physician.
  • Both HMO and PPO plans generally include prescription drug coverage through a Medicare Advantage Prescription Drug plan (MAPD).

About HMOs

You will need to choose a primary care doctor upon enrolling into most HMO plans, and most of the time this doctor will have to refer you to see a specialist. Some services, like yearly screening mammograms, do not require a referral.

Prescription drugs are covered under most HMO plans called Medicare Advantage Prescription Drug plans. Check with the plan you’re interested in first if you want it to include Medicare Part D prescription drug coverage.

If your physician leaves the plan’s network of providers, you will be notified of his or her departure. You can then select another doctor from within the plan’s network.

Another thing to remember is that if you use an HMO, you agree to receive coverage within that plan’s network except in urgent and emergency situations. You can still receive health care outside of the plan’s network, but be aware that the plan may not pay for these services.

About PPOs

Medicare Advantage PPO plans provide another managed-care option for beneficiaries who want greater provider flexibility. With a PPO plan, your out-of-pocket costs will generally be lower if you use doctors and hospitals in the plan’s preferred provider network. You may also choose to use out-of-network providers, but your copayment and coinsurance costs may be higher.

As mentioned, PPOs don’t require members to have primary care doctors, and referrals aren’t needed before seeing a specialist. If you prefer the convenience of getting specialist care directly, without needing a referral from a primary care physician, this may be one factor to consider when choosing between an HMO or PPO plan.

Like HMOs, you can get Medicare prescription drug coverage through your PPO plan by enrolling in a Medicare Advantage Prescription Drug plan. Keep in mind that not every PPO plan includes prescription drug benefits, and costs and benefits may vary by plan.

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Are newly acquired dependent children covered?

Your child or children born after your enrollment/effective date will be effective from the moment of birth (If they already have already enrolled dependents) and will remain in effect for 31-days. An adopted child or child placed with you for the purpose of adoption will be covered for 31-days from the date of adoption or placement. To continue the child’s coverage You must send us written notice directing us to add the child or children to your coverage. We must receive this notice within the 31-days after the child’s date of birth, adoption or placement. Any required additional premium must accompany your notice. If you do not send us the required notification and any additional premium, the child’s coverage will end after the 31-days.

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Will Medicare cover me if I travel to another state or country?

If you are a Medicare beneficiary with Original Medicare, Part A and Part B, you can travel anywhere in the United States and still be covered, as long as you use doctors and hospitals that accept Medicare. If you travel outside of the United States, however, your Medicare coverage is limited.

Please note that when it comes to Medicare coverage, “outside of the United States” includes any location outside of the 50 states, the District of Columbia, Puerto Rico, Guam, American Samoa, Virgin Islands, and the Northern Mariana Islands.

There are a few situations when Medicare may cover you outside of the country if you need medical care in a foreign hospital:

  • Medicare will cover health care in a foreign hospital if you live in the United States and have a medical emergency, but the nearest foreign hospital is closer to you than the nearest U.S. hospital.
  • Medicare may also provide coverage in Canada if you have a medical emergency while you’re traveling on a direct route, without unreasonable delay, between Alaska and another U.S. state, and the closest hospital that can treat you is in Canada. Medicare will determine on a case-by-case basis what qualifies as “without unreasonable delay.”
  • Medicare will also cover certain health-care services you get in a foreign hospital, regardless of whether it’s an emergency, if you live in the United States and the foreign hospital is closer to your home than the nearest U.S. hospital.
  • Medicare will also cover you while on a cruise ship if you need to receive medically necessary care while the ship is in U.S. waters or a U.S. port (or within six hours of arrival or departure from a U.S. port). The physician treating you must be legally allowed to provide medical care on a cruise ship.

In the above limited situations, Medicare may pay for inpatient hospital care, doctor services, and/or ambulance services. Please note that if you’re enrolled in Medicare plan that includes prescription drug coverage (such as a stand-alone Medicare Prescription Drug Plan), these plans don’t cover prescription medications that you purchase outside of the United States.

Traveling with Medicare Advantage plans

If you receive your Medicare coverage through a Medicare Advantage plan, instead of Original Medicare, the rules for out-of-state coverage are different and will depend on the type of Medicare Advantage plan you’re enrolled in. Certain types of Medicare Advantage plans, such as HMOs, have provider networks that you must use to be covered for routine care. You generally need to get health-care services from doctors and hospitals in the plan network, although you’ll still be covered if you need emergency medical care, out-of-area urgent care, or out-of-area kidney dialysis.

Other Medicare Advantage plans, such as PPO plans, are more flexible and may let you see health-care providers outside of your plan’s preferred provider network. Depending on the rules of your plan, however, you could have to pay a higher copayment or coinsurance to receive non-emergency care from an out-of-network provider. If you will be traveling out of state, contact your Medicare Advantage plan for more information on coverage while out of your plan’s service area.

If you are traveling overseas, Medicare Advantage plans must provide at least the same level of coverage as Original Medicare, so you’ll be covered in the same limited situations described above. However, some Medicare Advantage plans may provide additional coverage when you are traveling outside of the United States. Check with your Medicare Advantage plan for more information.

Medigap coverage outside of the United States

As another coverage option for Medicare beneficiaries traveling outside of the United States, some Medicare Supplement plans may offer emergency medical coverage when you’re out of the country. Also known as Medigap, these plans work alongside Original Medicare and may help with certain costs that Medicare doesn’t pay for.

Specifically, Medigap Plans C, D, F, G, M, and N provide some degree of emergency foreign travel coverage (up to plan limits). As mentioned, some Medicare Advantage plans provide coverage for travel abroad also.

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What are the customer service telephone numbers and hours of operation for the claims department?

If you have any questions please call:
Ameritas Group Claims Department at 800-487-5553
Representatives are available Monday – Thursday 7:00 am to 12:00 am (Central Standard Time)
and Friday 7:00 am to 6:30 pm (Central Standard Time)

Visit the Ameritas website at:
www.ameritasgroup.com

 

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How do I report a Medicare beneficiary’s death?

When the death of a Medicare beneficiary occurs, the family member or person responsible for the beneficiary’s affairs may notify Social Security; however, in most cases, the funeral home will report the person’s death to Social Security. If you want the funeral home to do that, you will need to give the deceased’s Social Security number to the funeral director so he or she can make the report. Otherwise, you can call Social Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778) between 7 AM and 7 PM, Monday through Friday.

If monthly benefits were being paid via direct deposit, the bank or other financial institution also needs to be notified of the beneficiary’s death. Any funds received for the month of death and any later months may need to be returned to Social Security.

If benefits were being paid by check, do not cash any checks received for the month in which the beneficiary died or thereafter. Return the checks to Social Security as soon as possible. A one-time payment of $255 is payable to the surviving spouse if he or she was living with the beneficiary at the time of death or if the surviving spouse was living apart from the beneficiary, but was receiving Social Security benefits from the beneficiary’s earnings record. If there is no surviving spouse, the payment is made to a child who was eligible for benefits from the beneficiary’s earnings record in the month of death. Certain family members may be eligible to receive monthly benefits. Contact Social Security to learn more.

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Is my doctor in my Medicare plan network? What if my doctor is not in network?

To avoid paying higher costs, it’s a good idea to make sure your doctor is a participating Medicare doctor and, if applicable, in your Medicare plan’s network.

Original Medicare

If you have Original Medicare, Part A and Part B, you can usually choose any doctor that is enrolled in Medicare. To find out if your doctor accepts Medicare assignment, you can do either of these:

  • Call the doctor and ask.
  • Use Medicare.gov’s Physician Compare tool. The finder tool lets you search through a list of physicians in your area to see which ones accept Medicare.

Medicare Advantage plans

Instead of receiving your benefits through Original Medicare, perhaps you opted for Medicare Advantage, also known as Medicare Part C. There are several different types of Medicare Advantage plans, but all of them are available from private, Medicare-approved insurance companies, and cover your Medicare Part A and Part B benefits. Hospice care is the only exception; Medicare Part A still covers this care if you’re enrolled in a Medicare Advantage plan. Many plans include additional benefits, such as prescription drug coverage and wellness programs. You still pay a monthly premium for Medicare Part B along with any premium the Medicare Advantage plan charges.

If you belong to a Medicare Advantage plan — for example, if it’s a Health Maintenance Organization (HMO) — the plan might have required you to choose a primary care physician from a list of doctors in the plan’s network. If you did this, you know the doctor is a participating Medicare provider within the plan’s service area. Your plan will notify you if the doctor leaves your plan.

If you did not have to choose a primary care physician when you enrolled in your Medicare Advantage plan — for example, if you are in a Preferred Provider Organization (PPO) — you can check with your plan provider to see if your doctor of choice is in the network.

In situations where your doctor is not in the plan’s network, you might need to change to a doctor who is in the network, or change Medicare Advantage plans. There are certain times when you can sign up for, or switch, Medicare Advantage plans.

In any case, it’s always a good idea to check with your doctor before any appointment to make sure he or she is still in the Medicare Advantage plan. If he or she is not in the plan, you might have to pay for services.

When you’re ready to compare plans and get quotes, you can use the simple form on this page to view the Medicare Advantage plan options in your area. Simply enter your zip code and then choose the sort of Medicare plan you are shopping for (such as Medicare Advantage) to see a list of what’s available near you.

Can I change my primary care provider?

In most cases it is possible for you to change primary care providers with Medicare Advantage coverage. You may want to make sure this is an option before enrolling in a plan, and use your plan’s instructions for changing providers.

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Where are the plans available?

To see if the plans are available in your state, simple register at the www.RealtorsInsuranceMarketplace.com website or call the toll free number provided. If you receive a quote from the website then the plans are available in your state. If the plans are not available we will set up a reminder to contact you once it is available.

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Does Medicare pay for medical services received aboard a cruise ship?

Medicare may pay for medically necessary services and supplies administered aboard a cruise ship if the ship was within United States waters when you got this care, and the doctor was authorized to provide this care to you. The services and supplies must be provided in a United States port or within six hours of departure or arrival at a U.S. port.

If you received care within U.S. waters, the doctor should submit a claim to Medicare. If you received care while in international waters, Medicare doesn’t generally cover it.

Some Medicare Supplement (Medigap) policies may cover emergency medical care outside the U.S.Medigap plans are available from private insurance companies to cover some of your Original Medicare (Part A and Part B) out-of-pocket costs.

You may also want to ask your travel agent about travel insurance with limited medical coverage.

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Where are REALTORS® Dental Insurance plans available?

To see if the plans are available in your state, simply register by clicking here or calling 877-267-3752. If you receive a quote from the website then the plans are available in your state. If the plans are not available we will set up a reminder to contact you once it is available.

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How do I qualify (eligible) for REALTORS® Dental Insurance?

  • be over age 18, unless a dependent of a member – There is no age limit to qualify for these plans
  • be an NAR member

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Who is an eligible dependent on REALTORS® Dental Insurance?

  • an Insured’s spouse.
  • each unmarried child less than 26 years of age, (less than 30 years of age for discharged military dependents), for whom the Insured or the insured’s spouse, is legally responsible, including:
    1. natural born children;
    2. adopted children, eligible from the date of placement for adoption;
    3. a grandchild that is a dependent of, and under interim court-ordered custody of the Insured;
    4. children covered under a Qualified Medical Child Support Order as defined by applicable Federal and State laws.
  • each unmarried child age 26 or older who:
    1. because of a handicapped condition that occurred before attainment of the limiting age, is incapable of self-sustaining employment; and
    2. is dependent on his or her parents or other care providers for lifetime care and supervision.

“Dependent on other care providers” is defined as requiring a Community Integrated Living Arrangement, group, home, supervised apartment, or other residential services licensed or certified by the Department of Mental Health and Development Disabilities, the Department of Public Health, or the Department of Public Aid.

Coverage of such child will not cease if proof of dependency and disability is given within 31 days of attaining the limiting age and subsequently as may be required by us but not more frequently than annually after the initial two-year period following the child’s attaining the limiting age. Any costs for providing continuing proof will be at our expense.

 

You can enroll your child or children born after your enrollment/effective date will be effective from the moment of birth (If they already have already enrolled dependents) and will remain in effect for 31-days. An adopted child or child placed with you for the purpose of adoption will be covered for 31-days from the date of adoption or placement. To continue the child’s coverage You must send us written notice directing us to add the child or children to your coverage. We must receive this notice within the 31-days after the child’s date of birth, adoption or placement. Any required additional premium must accompany your notice. If you do not send us the required notification and any additional premium, the child’s coverage will end after the 31-days.

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If I had dental coverage through another plan or will be losing coverage soon, can the waiting periods be waived?

Yes.   If you have had coverage within two months of enrolling in one of the NAR dental plans, the six month waiting period on Type 3 procedures and the 12 month waiting period on orthodontic benefits can be waived.   When enrolling, you will need to indicate that prior dental coverage existed for you and/or your covered dependents.   An ID card or EOB from the prior dental plan can be included to verify prior coverage and allow us to authorize the waiver of the waiting periods.

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If I have dental coverage through my spouse or another plan, does your plan coordinate benefits?

Yes.   If you have coverage other another group dental plan, Ameritas will coordinate the benefits between the two plans.   If you are covered as a dependent under a spouse’s plan, the NAR plan would be considered “Primary” for you as the NAR member, and “Secondary” under your spouses plan.   Your spouse would be considered “Primary” under their own coverage and”Secondary” under your NAR plan.   Note:  by coordinating benefits, the benefit between the two plans would equal no more than 100% of the total cost of the service.

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How do I make changes to my REALTORS® Dental Insurance plan?

For customer service, billing, and plan change questions please contact our customer service department at 1-800-279-2290.

Our office hours are M-F 8:30 to 5:00 central/standard time.

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When does REALTORS® Dental Insurance coverage begin?

Coverage becomes effective next day (12:01 am) following the date the completed enrollment form is received and approved, or a specified date in the future (not more than 30 days in advance), provided that full premium for the coverage has been received.

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When does REALTORS® Dental Insurance coverage end?

An insured Member’s coverage ends when the Member is no longer eligible (as defined above), premiums are discontinued (subject to the grace period), when the policy terminates, or when the Member is no longer in good standing with the association, whichever occurs first. Coverage on a dependent ends on the earliest date they no longer meet the definition of an eligible dependent or on the date the Primary Member’s coverage terminates, whichever occurs first.

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Will I receive an ID card for my REALTORS® Dental Insurance?

The ID cards and policy are mailed out to your residence, typically within 3 days via USPS. You should receive the policy and ID cards within two weeks.  If your provider does not accept the insurance you may obtain a claim form and submit the claims directly to Ameritas for processing.

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What does MCE mean?

Maximum Covered Expense (MCE): a simple, easy to understand benefit at a very affordable rate. Members know exactly what the plan pays for each covered procedure, and they pay the difference between that amount and the dentist fees. The MCE increases based on the plan you select. The Value Plan has the lowest MCE and Platinum Plan offers the highest level. Additional out of pocket savings occur when a member uses an Ameritas Preferred provider.

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Is Orthodontia available with REALTORS® Dental Insurance?

Yes. Under the Platinum, Gold and Silver plans, orthodontic benefits are available for children. Benefits are payable for orthodontic programs that were started before the dependent’s 17th birthday. The Platinum, Gold and Silver plans provide a $1,000 lifetime maximum benefit per eligible dependent child.

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Is Anesthesia covered under the REALTORS® Dental Insurance plans?

Yes. Anesthesia is covered under the Platinum, Gold and Silver plans.

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Do I have to use a PPO dentist to receive benefits?

No. All members and their covered dependents have the freedom to choose any licensed dental provider. The PPO providers available to you have agreed to negotiated fees, so out-of-pocket costs for the member are often much lower than using a non-participating provider.

As an added comfort, all PPO dentists have passed an extensive screening to ensure not only a saving to the plan but high quality care.

Not every dentist is able to meet Ameritas’ standards. Only those who adhere to Ameritas’ credentialing and quality assurance requirements are able to join and remain in the network. This process includes:

  1. State insurance department verification to confirm that dentists are licensed, and to uncover whether any disciplinary action has ever been filed
  2. Review of malpractice insurance and that no malpractice suits have been filed
  3. Legal department and dental consultant review of any license disciplinary action or discovery of malpractice suits.
  4. Certification of adherence to quality assurance guidelines as mandated by state and federal entities, including OSHA and the Center for Disease Control.

Ameritas re-credentials and conducts quality assurance visits on network providers periodically to make sure they continue to work within accepted parameters.

To find a provider that is part of the PPO Network, click here. Members can search for a specific provider by name, or search for dentists by an address or zip code location. Provider directories are updated on a daily basis. The Provider Relations Department has a toll free number (800.755.8844) to verify participating providers and answer questions about participating providers.

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How does REALTORS® Dental Insurance handle pre-existing conditions and work in progress?

The plan does not limit pre-existing conditions. Simply knowing a dental procedure is needed does not prohibit the plan from providing coverage. As long as the procedure is not incurred prior to the member’s effective date of coverage, the procedure is eligible for benefits based on the plan coverage.

Any procedures started prior to the member’s effective date of coverage will not be eligible under the plan.

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Do the REALTORS® Dental Insurance plans include any waiting periods before benefits are available?

Yes. On the Platinum, Gold and Silver plans, a six(6) month waiting period applies to all Type 3 Procedures before benefits are paid. A twelve (12) month waiting period applies to all Orthodontic Procedures before benefits are paid.

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Why should I consider a REALTORS® Core Health Insurance (Limited Medical) plan?

There are several important reasons why people purchase limited medical (also known as mini-medical) plans. In summary; to save money, to access to “Guaranteed Acceptance” policy, and to supplement another plan which has high out of pocket expenses.

Here are a few possible scenarios:

 

  • I do not qualify for a Special Enrollment Period to enroll in Major Medical insurance outside Open Enrollment: REALTORS® Core Health Insurance plans are available year round. You can enroll in this plan at any time, but it is important to remember that you may be subject to the federal tax penalty.
  • I cannot afford traditional medical insurance: REALTORS®’s exclusive “guaranteed acceptance” plans will cover your everyday healthcare needs – but it’s important to recognize that they are not major medical insurance. REALTORS® Core Health Insurance offers limited medical plans that are affordable and available to everyone because they provide set and limited dollar coverage for each medical service needed. 
  • I have major medical insurance but it is too expensive: An excellent way to save on medical insurance is to supplement a major medical plan with a REALTORS® Core Health Insurance plan. We recommend that you keep your major medical plan but increase your deductible and buy a RCHI plan to complement your major medical coverage.

Why would you increase your deductible? Because a program such as RCHI’s Physician Only plan may offer equivalent coverage for your everyday healthcare needs (such as office visits and wellness visits) but at a much lower cost than your current coverage through your major medical plan – allowing you to change the terms of your major medical coverage and save money.

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What happens if I apply for this insurance and then change my mind and decide that this policy does not fit my needs?

You have the right to review your policy within 10 days from the date you have applied. After you apply, you will automatically receive an email for you to review your application and certificate. If you do wish to terminate the coverage after you have reviewed the certificate, you will need to contact the customer service department by phone. We also require a written request with the policy holder’s signature. If you have provided the correct information within the 10 day time frame, a refund of premiums, minus the administration fees will be issued and your policy will be deemed void, as though it had never been issued.

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What are the customer service telephone numbers and hours of operation for the REALTORS® Dental Insurance claims department?

If you have any questions please call:
Ameritas Group Claims Department at 800-487-5553
Representatives are available Monday – Thursday 7:00 am to 12:00 am (Central Standard Time)
and Friday 7:00 am to 6:30 pm (Central Standard Time)

Visit the Ameritas website at:
www.ameritasgroup.com

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How do I cancel my REALTORS® Dental Insurance coverage?

Dental insurance policy cancellation procedure:

We are confident that this dental plan is the best plan available of its kind. We do care about you and your health and it is our job to make sure that your have secured dental insurance that will benefit your needs. If you have not obtained other insurance and have questions about this plan and the benefits it can provide for you and your family, please contact our customer service department at 1-800-279-2290.

If you are confident that this dental insurance is not going to give you the benefits you need and you have met your twelve month commitment, or you have obtained new group dental coverage, you can terminate this plan. In order to avoid any future payments to be drafted from your account. We do require a hand written signature no later than five days before the next scheduled draft date.

If you are requesting to cancel your plan and are within your 10 day right to review period, your hand written request is required within ten days from the effective date requested on your application. If required information is received in a timely manner, a refund of your premiums paid minus any enrollment fees will be issued to the account on file.

Scan and Email request with signature to: adminefax@sasid.com
or
Fax # : 608-531-2707
or
Mail request to:
InsuranceTPA.com/SASid
PO Box 998
Janesville WI 53547

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Is REALTORS® Core Health Insurance major medical insurance?

These plans are not major medical coverage and are not intended to replace other medical coverage. If you have major medical insurance, you may save money by increasing your out-of-pocket (deductible) and use these plans to supplement coverage. However, you should not cancel your major medical coverage.

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What is the difference between Major Medical and Limited Medical (REALTORS® Core Health Insurance)?

It is important to understand the difference between major medical and limited medical insurance. 

Major Medical provides comprehensive and catastrophic coverage. Because the cost of medical services continues to rise, many major medical insurance companies have increased the out-of-pocket costs for consumers, making the everyday cost of healthcare expensive.

Limited Medical (RCHI) provides coverage for everyday illness and accident at affordable rates by offering specific benefits with capped limits of coverage.
Limited Medical plans are useful in many situations:

  • Not eligible for a Special Enrollment Period to enroll in Major Medical insurance outside Open Enrollment: REALTORS® Core Health Insurance plans are available year round. You can enroll in this plan at any time, but it is important to remember that you may be subject to the federal tax penalty.
  •  Save money by supplementing current Major Medical Plan – If you have a major medical plan you can save money by increasing your current plan’s deductible (out of pocket). Then take advantage of the Realtors® Core Health Plans value for your everyday healthcare needs. The “Physician Only Plan” covers office, wellness visits, x-ray/lab and accident benefits at an affordable price.
  • Uninsured due to affordability – If you have done your research and you simply cannot afford major medical then a limited medical plan may be a last option. Designed to offer benefits at a value.

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Do I qualify/am I eligible for REALTORS® Core Health Insurance?

To be eligible for any RCHI plan you must be an active member of the National Association of REALTORS® and:

  •  be over age 18, unless an eligible dependent of a member
  •  be under age 65 (persons over the age of 65 should look into a Medicare supplement or similar plan) reside in a qualified* state of United States

*Click here (or call 877-267-3752) and register to see if a plan is available in your state. If you receive a quote then your state is available. If your state is not available we will contact you once we get approval from your state department of insurance.

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Are REALTORS® Core Health Insurance plans available in every state and the U.S. territories?

Our goal is to have a plan available in every state and territory. Although coverage is available in the majority of states today, there are some still awaiting approvals from the state department of insurance. To see if the plans are available in your state, simply click here to register or call 877-267-3752.

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Do I have to be a United States citizen to be eligible for REALTORS® Core Health Insurance?

No, but you must be a permanent resident of the United States for 12 consecutive months and have a valid Social Security Number.

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What is the difference between the three exclusive REALTORS® Core Health Insurance plans developed for REALTORS®?

  • The Physician Only plan – Designed to supplement and complement major medical plans that have high out-of-pocket cost (deductibles, coinsurance, etc.). Increasing your major medical deductible and adding this RCHI plan may help you save money.
  • The Value plan – Offers both physician and hospitalization/surgery benefits. This plan was designed for someone who is on a limited budget. This plan can also supplement a major medical plan that involves a large out-of-pocket cost.
  • The Platinum plan – Offers the richest benefits of the three REALTORS® plans: It offers physician, hospitalization/surgery, and other benefits. This plan was designed for REALTORS® members who would otherwise not be able to get insurance (“uninsurable” due to pre-existing medical conditions or other issues).

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What are the medical underwriting requirements of REALTORS® Core Health Insurance plans?

All members of the National Association of REALTORS® and their eligible dependants who satisfy the eligibility requirements are automatically accepted. The plans are “Guaranteed Acceptance”, which means as long as you meet the eligibility requirements and provide timely payment of premium you will be accepted into the program. There are no medical questions or exams to qualify.

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Are Pre-existing Conditions covered under REALTORS® Core Health Insurance and is there a waiting period?

Benefits such as doctor office and wellness visits; accident, x-ray and laboratory benefits have no pre-existing limitation clause on these plans.

However, benefits under Hospital, ICU/CCU, Surgery or Anesthesia are not payable for any pre-existing condition for the first 12-months following an insured’s effective date.

There is a 30 day waiting period for services rendered for illness and sickness (illness or disease) from the effective date of the policy.

There is no (0 day) waiting period for accident related services.

NOTE: Please review your policy for any additional limitations and exclusions.

If you have access (states availability varies) to the PPO (prefered provider option) you may receive up to 40% on services covered and/or not covered (pre-existing, waiting period, excluded) by the REALTORS® Core Health Insurance plans.

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I have current medical conditions; do I still qualify for REALTORS® Core Health Insurance?

These plans are “Guaranteed Acceptance”; as long as you meet the eligibility requirements you qualify. The 12-month pre-existing condition provision, will apply to any Hospital, ICU/CCU, Surgery or Anesthesia.

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Do the REALTORS® Core Health Insurance plans cover pregnancy/maternity care?

No, these plans do not cover normal pregnancy. However, they do cover complications of pregnancy.  Also, if you utilize the PPO (Preferred Provider Option) you may recieve up to 40% discount on your pre and post maternity services.

The best option if you are planning to become pregnant and need coverage is to try to acquire a group policy through an employer or acquire an individual major medical policy. You can do this during Open Enrollment, or through a Special Enrollment Period (click here to learn more about special enrollment periods). You should plan ahead and access a major medical or group plan before you become pregnant. If you’re unsure what to do, always call a licensed benefit specialist who can advise you of your options at 877-267-3752.

If you are currently pregnant – you will need group coverage through an employer (which has maternity coverage). Individual major medical plans are a good option too, but you can only enroll during Open Enrollment or if you have a qualifying event that triggers a special enrollment period.

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What is the definition of Pre-existing Condition limitation under REALTORS® Core Health Insurance?

Pre-existing Condition means a medical condition, Injury or Sickness, not excluded by name or specific description, for which:

  1.  Medical advice, Consultation, care or treatment was recommended by, or received from, a Doctor within 12-months immediately prior to the Effective Date of coverage for a Covered Person; or
  2. Symptoms existed within 12-months immediately prior to the Effective Date of coverage for a Covered Person that would cause a reasonable person to seek Consultation, care, or treatment from a Doctor.

“Consultation” means evaluation, diagnosis, or medical advice given without the necessity of a personal examination or visit.

The Pre-existing Condition limitation only applies to Surgery, Anesthesia, Hospital, and ICU/CCU benefits.

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Can I have another medical insurance plan in addition to REALTORS® Core Health Insurance?

Yes, and it may be an excellent way for you to save money. For example; Jimmy is paying $800 for his $250 deductible major medical policy. If Jimmy increases his deductible to $1,500 his premiums go down to $550 per month. With his savings of $250 per month he is able to purchase the “Physician Plan” which will cover his Office/Wellness visits and Accident benefit. Because the plans are affordable, Jimmy has supplemented his current plan and saved money.

However, please note that you may not be covered under more than one REALTORS® Core Health Insurance plan per person.

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If I apply for an insurance plan, am I obligated to buy?

No. You are under no obligation to buy a health insurance plan when using our site.  After submitting your application you may cancel it at any time during the underwriting process.  When you submit an application you will typically include your credit card number, bank account information, or a check for the initial premium payment.  Most insurance companies will not charge your card, debit your account, or deposit your check until you are approved.  If you are charged or your check is cashed and you are denied for coverage or cancel your application prior to approval, the insurance company will issue a refund.  A few insurance companies will charge an application fee .  You will be notified at the time of application if the plan you chose require an application fee.  Please note that these fees are non-refundable.

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Will I receive an insurance ID card for REALTORS® Core Health Insurance?

You will receive instant access to printable RCHI ID cards once you enroll. To apply, click here. Also, plastic cards are mailed out to your residence within 3 days of enrollment via USPS. You should expect to receive them no later than two weeks.

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When does REALTORS® Core Health Insurance coverage begin?

Coverage becomes effective next day (12:01 am) following the date the completed enrollment form is received and approved, or a specified date in the future (not more than 30 days in advance), provided that full premium for the coverage has been received. Note: Please check your policy for information on pre-existing conditions, waiting periods and other limitations and exclusions.

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When does REALTORS® Core Health Insurance coverage end?

An insured Member’s coverage ends when the Member is no longer eligible (see your policy’s eligibility questions), premium payments are discontinued (subject to the grace period), when the policy terminates, Member reaches age 65, or when the Member is no longer in good standing with the association, whichever occurs first. Coverage on a dependent ends on the earliest date they no longer meet the definition of an eligible dependent or on the date the Primary Member’s coverage terminates, whichever occurs first.

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What are the payment options for REALTORS® Core Health Insurance?

Online payment is the most popular choice; you can arrange for manual payments each month or you can set up automatic payments that are withdrawn from your credit card or checking/savings account. You can check the status of your payments online. You may also set up email alerts to let you know when payments will be withdrawn. Another option is to have paper bills sent to your address of residence. Extra fees may apply for this payment option.

Monthly Options:

If you have chosen a payment method of Credit Card or EFT your payments will be deducted from that account given on the scheduled billing date each month. It is set up for you automatically so you have the peace of mind that your payments will not be missed.

If you choose the offline payment option, you will then be responsible for mailing in the payments each month on the scheduled billing date. Payment coupons will be sent to you to help you remember your billing date.  Extra fees may apply for this payment option.

 

Mail payments to:

Realtors® Core Health Plans
P.O. Box 998
Janesville, WI 53547

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Is there a place where I can go online to view my payment history?

Yes. All members have access to the customer service login. You will be able to view not only payment information, you will have access to view claim status, billing, cancellation procedure and even the links to view your certificate, plus more!

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I missed a payment for my REALTORS® Core Health Insurance plan. Is there a grace period?

Your policy gives you 31 days from the due date to post a new payment. If a payment has not been posted within that time, your policy will terminate due to nonpayment. Your insurance coverage dates will reflect the approved payments made.

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What happens if I review my REALTORS® Core Health Insurance application and notice that some of my personal information is incorrect?

If changes need to be made on an application, you will need to contact the customer service department at 1-800-279-2290 or send us an email from your customer service login.

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Who is an eligible dependent under REALTORS® Core Health Insurance?

Eligible Dependent means:

  1. Your lawful spouse; and
  2. Your child(ren) age 26 and younger.

“Child” includes stepchild, foster child, legally adopted child, a child of adoptive parents pending adoption proceedings, and natural child.

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Are newly acquired dependent children covered under REALTORS® Core Health Insurance?

Your child or children born after your enrollment/effective date will be effective from the moment of birth and will remain in effect for 31-days. An adopted child or child placed with you for the purpose of adoption will be covered for 31-days from the date of adoption or placement. To continue the child’s coverage You must send us written notice directing us to add the child or children to your coverage. We must receive this notice within the 31-days after the child’s date of birth, adoption or placement. Any required additional premium must accompany your notice. If you do not send us the required notification and any additional premium, the child’s coverage will end after the 31-days.

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When should I enroll my dependents under REALTORS® Core Health Insurance?

Eligible dependents should be enrolled at the time of application. If you would like to add dependents at another time, you may but they will have their own preexisting condition limitation (12/12) clause (see preexisting condition definition) and waiting period (30 days for sickness related conditions, 0 for accident) to satisfy. Dependents enrolled at a later date will take effect at the following month renewal date.

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How do I add a person to a REALTORS® Core Health Insurance plan after the effective date?

To add a person, you must:

  • Complete and submit a new enrollment application by clicking here for such person for approval; and
  • Contact billing (1-877-279-2290; or email rchi@sasid.com), request “Change Authorization Request Form”, complete form, and send in to SASid (PO Box 998, Janesville, WI 53546)
  • Pay any additional premium required

If the application for coverage of the new Eligible Dependent is approved, the Effective Date of such person’s coverage will be shown by an endorsement to your certificate.

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Can I use any doctor, clinic, or hospital with REALTORS® Core Health Insurance?

Yes. Covered members and dependents can use any licensed medical provider. Some states have a PPO (preferred provider option) available which may provide additional savings to the insured(s). We encourage members to use this valuable benefit when available.

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Is there a provider network of doctors (PPO option) with REALTORS® Core Health Insurance?

You may go to any licensed physician or hospital with these insurance plans. In some states there is a PPO network option (based on state availability) which can provide additional savings on your healthcare, if you choose to use it.

Preferred Provider Organizations (PPOs) have negotiated discounts with providers (doctors, hospitals, etc.) nationwide. By utilizing providers in these networks you can save money on your healthcare. The PPO networks are an option for you and are not mandatory, although it is typically in your best interest to use a PPO provider. Based on your state of residence REALTORS® Core Health Insurance Plans will add a PPO network (if available) to your plan automatically.*

The REALTORS® Core Health Insurance Plans utilize the MultiPlan PPO network.  The network has almost 900,000 providers nationwide.  When you request a quote or purchase a RCHI plan if the network shows up (“Quotes” or “My Plans”) then it is available to you (you will be able to search providers here also).  If the network does not show up then it is not available in your state at this time.  You may also call  877-267-3752 to find out if the network is available in your state.

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Will these REALTORS® Core Health Insurance plans cover all of my medical expenses?

No, limited plans are very clear in what they cover. If it is not on the schedule page of benefits then it is likely not covered. It is important that you review the plan details for exclusions and limitations information. Call a representative at 1-877-CORE-PLAN to discuss your options.

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Are prescriptions covered under REALTORS® Core Health Insurance?

All plans include a discount prescription drug card. You can save up to 50% on generic brands and up to 15% on brand names.

The definition of a generic drug is: A generic drug is a medication that has met the standards set by the Food and Drug Administration (FDA) to assure its bioequivalency to the original patented brand name medication. Once a generic drug is approved by the FDA as being bioequivalent, its level of safety, purity, strength and effectiveness is the same as the brand name product.

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How do I cancel my REALTORS® Core Health Insurance policy?

Policy cancellation procedure:

(1) Fax (or scan and email) us a written request for cancellation a minimum of 5 days prior to the billing date. U.S. Mail is an option as well, but remember that the request must be received 5 days prior to the current month’s billing  date. The automatic billing date is the date of the 1st payment made. Any requests received less than 5 days prior to the current month’s billing date will be processed for cancellation before the next month’s billing date.

(2) Include:
-the policy holder’s Name & Address
-the policy holder’s Date of Birth
-the policy ID number
-the date the policy is to be cancelled
-the reason for cancellation
-the policy holder’s signature

(3) Our fax number is 608-755-7955 Alternate Fax 253-595-6901. Our Mailing address is:

Insurance TPA
PO Box 998
Janesville, WI 53547

(4) Attn. Customer Service and Billing Dept.

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What is the best health insurance plan for me?

Choosing between different health insurance plans isn’t always easy.  There is no one “best” plan for everyone.  the est match for your and your family may be different that the best match for someone else.  In order to help you answer this question, here are a few things to consider:

1. Are you going to need long term coverage or just something for short term?
If you are between jobs for 1-6 months,  you may want to look int our short term coverage options.  Alternatively, if you have no prospects of receiving group health insurance coverage through an employer, you may value the stability and increased benefits offered through an individual or family health plan option.
2. Are you looking for basic coverage or more comprehensive coverage?
Some insurance plans offer basic coverage to cover  you in case of a major accident or illness.  These insurance plans typically have a lower month premium than plans with more comprehensive coverage and may be appropriate  for people who intend to use their insurance primarily in the event of a serious illness or accident.
3. Would you rather pay for your services before you use them or when you use them?
Typically, the higher the monthly premium that you pay, the less you will pay per doctor’s visit in co-payments and deductible.s  if you choose a health insurance plan with a low monthly premium, you’re likely to have a higher co-payment or deductible.  If you don’t anticipate making frequent  use of your health insurance coverage, a higher deductible plan with a lower monthly premium may suit you best.

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How can I view quotes and shop online through your website?

Shopping with us is simple.  After entering your zip code and some basic information about yourself, and your family if applicable, you will be provided with a list of health insurance plans available in your area.  You may refine these results or sort and organize them in various ways (deductible, co-insurance, price).  You will also have the opportunity to select several of them at a time to make more detailed  plan comparisons. Once you have selected a plan, you will fill out an application, providing more information about yourself, and your family if applicable, and health history.  Once your application is complete, we will work with the insurance company to help you receive a quick coverage determination.

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What is Temporary Health Insurance?

Temporary Health Insurance (A.K.A. Short Term Medical) is an ideal type of medical insurance for those who are: unemployed, in between jobs, recent college graduates, in need of an alternative to COBRA. You will see that this coverage provides many features while maintaining a very competitive premium structure.

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Who is eligible for short term medical coverage?

You and your spouse under age 65 (and not eligible for Medicare) and you and your spouse’s unmarried dependent children under age 19 (or under age 25 if a full-time student) who have a social security number and can answer “No” to the seven health questions on the application. Children age 19 and over should apply separately.

 

Child-only coverage is available for ages 2 through 18. The application must be completed and signed by the parent or legal guardian.

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How does short term medical coverage work?

The benefit options for covered expenses are per insured person per coverage period. First, you meet your deductible. Choose from four options: $250, $500, $1,000 or $2,500. Then we pay 80% or 50% of the next $5,000 of covered expenses.

After this, we pay 100% of covered expenses up to your lifetime maximum of $1 million per certificate.

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What is individual and family health insurance?

Individual and family health insurance is a type of health insurance coverage that is made available to individuals and families, rather than to employer groups or organizations. Given the option, most people would prefer to have their employer provide group health insurance coverage. But, if this is not an option for you, it is still important for you to seek coverage. You may be pleasantly surprised with the variety and affordability of the individual and family health insurance options available.

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Do I have the option to select my doctors, hospitals, and medical providers with short term medical insurance?

Yes. You have the freedom to go to any of the doctors and hospitals of your choice. This plan is not an HMO or PPO.

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How long may I be insured under this short term medical plan?

STM is issued on a temporary need and expires at the end of the period applied for (up to 6 months at a time). If the need for temporary health insurance continues, you may apply for another new STM* coverage period. Your application is subject to the eligibility and underwriting requirements. Furthermore the coverage is not continuous. Any condition that incurred expense during the last coverage period will be treated as a Pre-Existing Condition, and excluded under the next coverage period. Applicants over the age of 64 are not eligible to re-apply for coverage.
*Only if an STM Plan is available in your resident state at that time; plan benefits, premium and features may vary.

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What kinds of individual and family insurance plans are available?

Individual and family health insurance plans are usually described as either “indemnity” or “managed-care” plans.  Put broadly, the major differences concern choice of healthcare provider, out of pocket costs and how bills are paid.  Typically, indemnity plans offer a broader selection of healthcare providers than managed care plans.  Indemnity plans pay their share of the costs for covered services only after they receive a bill (which means that you may have to pay up front and then obtain reimbursement from your health insurance company),

There are several different types of managed-care health insurance plans.  These include HMO, PPO and POS plans.  Managed-care plans typically make use of healthcare provider networks.  Health care providers within a network agree to perform services for managed-care plan patients at pre-negotiated rates and will usually submit the claim to the insurance company for you.  In general, you will have less paperwork and lower out-of-pocket costs with a managed care health insurance plan and a broader choice of healthcare providers with an indemnity plan.

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Are pre-existing conditions covered under short term medical insurance?

This plan does not provide benefits for pre-existing conditions, work related conditions, and preventive care. If you or a dependent have an existing health condition, you may want to consult with your independent insurance agent prior to applying for or changing health/medical insurance. Insurance fraud is a crime. Any person who, with intent to defraud or knowingly facilitates a fraud against an insurer, submits an application or files a claim containing false, deceptive and/or incomplete information is subject to civil and criminal prosecution.

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How does a PPO plan work?

As a member of a PPO (Participating Provider Organization) plan, you will be encouraged to use the insurance company’s network of doctors and hospitals.  These healthcare providers have been contracted to provide services to the health insurance plan’s members at a discounted rate.  You typically won’t be required to pick a primary care physician but will be able to see doctors and specialists within the network at your own discretion.

You will probably have an annual deductible to pay before the insurance company starts cover your medical bills.  You may also have a co-payment for certain services or be required to cover a certain services or be required to cover a certain percentage (coinsurance) of the total charges for your medical bills.

With a PPO plan, services rendered by an out-of-network physician are typically covered at a lower percentage than services rendered y a network provider.

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Are there expenses not covered under this short term medical plan?

Yes, this plan is designed to protect you in the event of an illness or injury and is not meant to cover routine exams and preventive care. Short Term Medical is for temporary coverage only and therefore does not include some of the benefits a permanent health plan offers. Please refer to the Exclusions and Limitations section of this web site.

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How does an HMO plan work?

Though there are many variations, HMO (Health Maintenance Organizations) plans typically enable members to have lower out-of-pocket healthcare expenses but also offer less flexibility in the choice of physicians or hospital than other health insurance plans.  As a member of a HMO, you will be required to choose a primary care physician (PCP).  Your PCP will take care of most of your healthcare needs.  Before you can see a specialist, you will need to obtain a referral from your PCP.

With an HMO, you will likely have coverage for a broader range of preventive healthcare services than you would through another type of plan.  You may not be required to pay a deductible before coverage starts and your co-payments will likely be minimal.  With an HMO plan, keep in mind that you will  have no coverage for services rendered by a non-network provider or for services rendered without a proper referral from you PCP.

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Can I get a refund of my premium if I am not satisfied with this short term medical plan?

Once you receive your Certificate of Insurance, carefully review all information. If you are not satisfied for any reason, return the Certificate of Insurance (within 10 days of receipt) with your written request for cancellation to InsuranceTPA.com. Coverage will be cancelled as of the effective date and you’ll receive a full premium refund (minus admin fees), no questions asked. Send written request for cancellation with your signature to:

InsuranceTPA.com
PO BOX 998
Janesville, WI  53547

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How does a POS plan work?

A POS (Point of Service) plan combines some of the features offered by HMO and PPO plans.  As with an HMO, members of a POS plan are required to choose a primary care physician (PCP) from the plan’s network of providers.  Services rendered by your PCP are typically not subject to a deductible.  Also, like HMOs, a POS plan typically offers coverage for preventative care visits.

You may recieve a higher level of coverage for services rendered or referred by your PCP.  Services rendered by a non-network provider may be subject to a deductible and will likely be covered at a lower level.  If services are rendered outside of the network, you will likely have to pay up front and submit a claim to the insurance company yourself.

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How is short term medical coverage billed?

After submitting your enrollment form with first month’s premium, you will then be billed monthly or you can choose to prepay. You indicate on your enrollment form how you wish to pay for your coverage. You may elect to be billed for the monthly premiums (plus the administration fee), OR you can select one of the other two payment methods: (1) Automatic Pre-authorized Bank Withdrawal; or (2) Credit Card – MasterCard and Visa are accepted.

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How does an indemnity plan work?

A traditional Indemnity plan offers a great deal of freedom in choosing which doctors and hospitals to use, but will probably involve higher out-of-pocket costs and more paperwork.  Under an Indemnity plan, you may see whatever doctors or specialty you like, with no referrals required.  Though you may choose to get the majority of your basic care from a single doctor, your insurance company will not require you to choose a primary care physician.  An Indemnity plan may also require that you pay up front for services and then submit a claim to the insurance company yourself.

You may have an annual deductible that will need to be met before the insurance company begins to pay on your claims.  Once your deductible has been met, the insurance company will typically pay your claims at a set percentage of the “usual and customary” (UCR) allowance for that services. The UCR rate is the amount that healthcare providers in your area typically charge for any given service.

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When does short term medical coverage begin?

The insurance can be effective as early as 12:01 a.m. the next day after the transmission date. However, the applicant can choose a later effective date not to exceed 60 days from transmission date. Coverage ends on expiration date listed in your coverage document.

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How does a HSA work?

Legislation establishing Health Savings Accounts (HSA) took effect on January 1, 2004.  HSAs and HSA eligible health insurance plans are becoming more and more popular.  Here are the basics:

  • A HSA is a tax-favored savings account that may be used in conjunction with a HSA-elgibile high deductible health insurance plan to pay for qualifying medical expenses.
  • Choosing an HSA-elgible plan may help you save money.  Typically, the monthly premium on an HSA-elgible high deductible plan is less expensive than the monthly premium for a lower deductible insurance plan.
  • Contributions to an HSA may be made pre-tax, up to a certain annual limit.
  • Funds in the HSA may be invested at your discretion.  unused funds remain in the account and accrue interest year-to-year, tax free.
  • Not all high-deductible plans are elgibile for use in conjunction with a HSA.

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Can I change my deductible on my short term medical plan?

No, Deductible changes cannot be made after the policy has been issued.

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Can I add additional family members to my short term medical plan?

No, to add additional family members you need to have the new family members apply on a separate policy.

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What is a co-payment?

A “co-payment” or “co-pay” is a specific charge that your health insurance plan may require that you pay for a specific medical service or supply.  For example, your health insurance plan may require a $30 co-payment for an office visit or brand-name prescription drug, after which the insurance plan pays the remainder of the charges.

For more information about co-payments, click here.

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What is a deductible?

A “deductible” is a specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims.  Not all health insurance plans require a deductible.  As a general rule, though there are may exceptions, HMO plans typically do not require a deductible, while most Indemnity and PPO plans do.

To see more information about deductibles, click here.

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Can I change my effective date on my short term medical plan?

No, once the policy has been issued you cannot change the effective date.

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How long can I purchase short term medical coverage?

The minimum amount of days you can purchase is 30.  You may purchase coverage for up to 6 months.  After the 6 months you may apply for a new short term medical plan.

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What is the difference from monthly payment option compared to single payment option with a short term medical plan?

Month-to-month coverage is available for persons who do not know how long they will need coverage.  Coverage is provided month-to-month until you terminate coverage (written request) or you reach the 6 month maximum coverage.

Single payment coverage option is the exact number of days of coverage you want.  This option works great if you know exactly the amount of days of coverage you need.  For example; if you have group coverage starting in 45 days you can purchase 45 days of temporary health insurance coverage to satisfy the gap.  Single payment option also provides a discount in the rates.

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What is a coinsurance?

“Coinsurance” is a term used by health insurance companies to refer to the amount that you are required to pay for a medical claim, apart from any co-payments or deductible.  For example, if you health insurance plan has a 20% coinsurance requirement then a $100 medical bill would cost you $20.00 and the insurance company would pay the remaining $80.00.

 

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After my short term medical coverage ends, may I apply again for additional months?

Temporary Health Insurance plans are not renewable.

 

However, if your temporary need continues beyond your policy period, you may apply for a new plan under the following circumstances:

  • No claims were incurred under a previous Short Term Medical plan.
  • There has been no significant change in your health.
  • You still meet the eligibility requirements to obtain a new policy

Any previous or current health condition or symptom will be considered a pre-existing medical condition that will not be covered under a new plan. There is no continuous coverage between plans — therefore your new plan will not provide benefits for any condition or symptom which began during a previous plan. In addition, no benefits are available for any period in which you are not covered by a Short Term Medical plan.

 

To obtain an additional plan, you must complete a new enrollment form. If the enrollment form is approved, a new plan will be issued.

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What is the difference between in-network and out-of-network providers?

An in-network provider is one contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates.  An out-of-network provider is one not contracted with the insurance plan.  Typically, if you visit a physician or other provider within the network, the amount you will be responsible for paying will be less than if you go to an out-of-network provider.  Though there are some exceptions, in many cases, the insurance company will either pay less or not pay anything for services you receive from out-of-network providers.

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Can I insure just my child(ren)?

When getting quotes for your child(ren) only, enter the child’s gender and birth date in the “Applicant” or first row.  Additional children should be entered below that field in the “Child” rows, but not the “Spouse” field.  However, many health insurance companies require one policy per child.  So if you have more than one child, try entering just the one child to see a larger selection of plans and prices.  You are free to apply for each child separately.

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Is a Short Term Medical plan considered “creditable coverage” under HIPAA?

Under HIPAA, Short Term Medical coverage is generally considered creditable coverage to help satisfy any pre-existing condition period.* Previous creditable coverage includes: 

  • A group health plan
  • Health insurance coverage
  • Part A or Part B of title XVIII of the Social Security Act (Medicare)
  • Title XIX of the Social Security Act, other than coverage consisting solely of benefits under section 1928 (Medicaid)
  • Chapter 55 of title 10, United States Code (Champus)
  • A medical care program of the Indian Health Service or of a tribal organization
  • A state health benefits risk pool
  • A health plan offered under chapter 89 of title 5, United States code (Federal Employee Health Benefit Plan)
  • A public health plan (as defined in regulations)
  • A health benefit plan under section 5(e) of the Peace Corps Act

* State reform legislation may vary; consult your state for specific rights and requirements.

 

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Does NAR offer a national Major Medical group insurance plan?

In an effort to find a healthcare solution, many members turn to NAR hoping that the Association offers a national group major medical insurance plan. Although group medical insurance plans are available to corporations for their employees, “A” rated insurance companies have been reluctant to offer such plans on a national scale to associations for their members, particularly when the members are independent contractors and participation in a plan is voluntary. This is because of the complexity and administrative burden of offering a group insurance program that meets the differing requirements of the fifty states. Click here to learn more.

If you are in need of Major Medical; SASid (the administrator of REALTORS® Core Health Insurance) has experts which can provide you with a recommendation.

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How does the Members Major Medical Plans system work?

It’s simple and fast… members can shop, compare, and enroll in Major Medical insurance online or over the phone with a licensed representative.  We have a dedicated team of helpful, licensed insurance representatives who will not pressure you to buy. Our team is here to help you understand, compare, and strategize your options.

Quote, Compare, Sort, and Apply.  The Members Major Medical Insurance Marketplace will shop top-rated carriers nationwide.

 

Quote:  Insurance carriers include, but are not limited to:

  • Blue Cross Blue Shield (varies per state)
  • Aetna
  • United Health (Golden Rule)
  • Celtic
  • Kaiser
  • Additional regional and state insurance companies

Compare:  PPO, HMO, or Indemnity Plans available on the exchange include:

  • Health Savings Account (HSA) Qualified plans
  • High Deductible (Catastrophic Plans)
  • and more…

Sort:  The Member Major Medical Insurance Marketplace allows you to quickly sort plans by multiple variables, including:

  • Carrier
  • Deductible(s)
  • Price (lowest to highest)
  • Types of plans and more
  • Types of coverage (Prescription, Maternity)

Enroll:

You can enroll online or speak to a licensed insurance representative by phone.  It takes only minutes to enroll with most major insurance companies.

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How does health care reform affect me?

The Affordable Care Act (ACA) mandates that all Americans must have minimal major medical coverage (this is also known as essential benefits) or pay a penalty.

We know that finding the right health insurance can be tough, and that health care reform can be confusing. We understand the mandates of the Affordable Care Act and the ongoing changes in health care reform. Rest assured. We are experts, so you don’t have to be!

Give us a call. Our licensed benefit specialists are available to personally consult and advise you on your individual insurance needs. We help NAR members navigate the complex and often confusing world of PPOs, HMOs, HSAs, supplement plans, and more.  We can help you understand what you need to do and the options that are best for your situation.

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What is a Qualified Health Plan?

A Qualified Health Plan, or QHP, is a plan that meets the standards set forth by the ACA.  Only by purchasing a QHP (or continuing on one you’re already a member of) can you escape the yearly penalty.

REALTORS® Insurance Marketplace will offer health insurance plans that are certified as qualified health plans, or QHPs. These QHPs must be licensed and accredited, and must meet certain requirements for transparency. To become certified, a QHP must meet a minimum set of criteria, including the following:

  • Coverage, at a minimum, of a comprehensive package of benefits, known as essential health benefits, or EHB
  • Benefit design standards, including non-discrimination requirements and limits on cost-sharing
  • Network adequacy standards

We encourage you to contact a licensed SASid representative at 877-267-3752 who will help you decide which exchange (public or private) and/or health plan is going to suit your needs best.

NOTE: Some plans offered on the RIM are not considered QHPs. Purchasers of such plans who don’t also have a QHP will have to pay a penalty.  Sometimes this can be a favorable strategy when looking to save money.

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What are Essential Health Benefits (EHB)?

These are services that Qualified Health Plans (QHPs) are required to cover under the Affordable Care Act.   Essential health benefits, as defined in Section 1302(b) of the Patient Protection and Affordable Care Act, will include at least the following general categories:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness and chronic disease management
  • Pediatric services, including oral and vision care.

Women’s preventive health services were defined in detail via federal regulations published August 1, 2011, requiring broad coverage, without copayments or deductibles of:

  • Annual preventive-care medical visits and exams
  • Contraceptives (products approved by the FDA) – with exemptions for religious employers and a temporary enforcement safe harbor.
  • Mammograms
  • Colonoscopies
  • Blood pressure tests
  • Childhood immunizations
  • Domestic violence screenings for interpersonal and domestic violence should be provided for all women
  • H.I.V. screenings
  • Breast feeding counseling and equipment, including breast pumps at no charge.
  • Gestational diabetes in pregnant women screening
  • DNA tests for HPV as part of cervical cancer screening

Coverage provided for the essential health benefits package will provide bronze, silver, gold, or platinum level of coverage (described below).  A health plan providing the essential health benefits package will be prohibited from imposing an annual cost-sharing limit that exceeds the thresholds applicable to HSA-qualified HDHPs.   Small group health plans providing the essential health benefits package will be prohibited from imposing a deductible greater than $2,000 for self-only coverage, or $4,000 for any other coverage (annually adjusted thereafter).  Such limits will be applied in a manner that will not affect the actuarial value of any health plan, including a bronze level plan (described below). Consistent with the immediate reforms described above, plans providing the essential health benefits package will be prohibited from applying a deductible to preventive health services.

PPACA will require the Secretary to define and periodically update coverage that provides essential health benefits. The Secretary will ensure that the scope of essential health benefits is equal to the scope of benefits under a typical employer-provided health plan (as certified by the Chief Actuary of the Centers for Medicare and Medicaid Services).   A health plan will be allowed to provide benefits in excess of the essential health benefits defined by the Secretary.

However, if a state requires such additional benefits in QHPs, the state must reimburse individuals for the additional costs of those benefits.

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What Do the Bronze, Silver, Gold and Platinum designations mean?

All major medical health insurance plans for individuals and small employers will be assigned a bronze, silver, gold and platinum benefit level.  A Catastrophic option will also be available to those under the age of 30.

These new Catastrophic, bronze, silver, gold and platinum benefit levels actually refer to a plan’s actuarial value level… or “AV.”

You’re probably wondering, What is actuarial value?

The easiest way to explain it is to say that it is the percentage of total average costs for the benefits a plan covers within a given year.

So, a plan with a 70% actuarial value would typically cover 70% of the costs and the customer would typically be responsible for 30% of the costs after the plan’s out of pocket expenses have been met.

The different “AVs” have metallic designations:

  • A bronze plan is 60 percent
  • A silver plan is 70 percent
  • A gold plan is 80 percent
  • A platinum plan is 90 percent

Insurers may also offer catastrophic-only coverage to eligible individuals under the age of 30, which would have higher cost-sharing than the standard Metallic plans.

“Metal levels” are designed to allow consumers to compare plans with similar levels of coverage, based on monthly premiums, provider networks, and other factors with the goal of helping consumers make more informed decisions. The graphic below also helps explain these metallic levels:

 

 

Metalic Levels

 

 

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What is the difference between a Public exchange and a Private exchange?

The Affordable Care Act provides public exchanges (or marketplaces).  You as a consumer have the option to shop for your health insurance through either type of exchange and there are pros and cons associated with both.  The REALTORS® Insurance Marketplace (RIM) offers both exchanges (public and private).

Below is a snapshot of the differences between the Public and Private:

Marketplace Differences

Public

Private

Who sponsors it? Government entity – either a state or the federal government.  Depending on where you live; each state has decided to build its own exchange or default to the Federal.  Insurance agents can offer and enroll consumers into the public exchange. Private company such as the NAR Members health insurance exchange.
What does it offer? Primarily health, dental, and/or vision insurance through multiple carriers which have been approved by the government. Health, dental, vision, plus an array of other insurance products ranging from supplemental to life to critical illness to more – through multiple carriers
Who uses it? Primarily individuals buying insurance and small businesses with up to 100 employees Primarily individuals, self-employed people, employees, and retirees of sponsoring organizations.
Who pays? Consumer, small employer, or both (federal subsidies are available to individuals with household incomes up to 400% of federal poverty level). Consumers (both employed and self-employed individuals) and employers
Is coverage Guaranteed Acceptance? Yes, all plans on the public and private exchanges are guaranteed acceptance (meaning you cannot be turned down based on medical history). Yes, all plans on the public and private exchanges are guaranteed acceptance (meaning you cannot be turned down based on medical history).
 “What types of plans are offered?”  All plans must include minimum essential health benefits.  Plans are from various insurance companies and will offer five levels; Catastrophic (Only available to individuals under the age of 30), Bronze, Silver, Gold, and Platinum. All plans must include minimum essential health benefits.  Plans will vary based on plan design, geographical location, and insurance company.  You will find different insurance companies and offerings on private exchanges.  Many insurance companies have opted out of public exchanges.
Will all insurance companies from my state be represented on each exchange?  I guess the point we are trying to make here is that it is beneficial to explore both public and private exchanges.  No. Some insurance companies have decided to be on the public exchange, others on the private exchange, and still others on both. It is beneficial to explore both public and private exchanges.

No. Some insurance companies have decided to be on the public exchange, others on the private exchange, and still others on both. It is beneficial to explore both public and private exchanges.

In general, private exchanges will offer more selection and options (more plan designs), which means lower costs.  However, you cannot get a subsidy on a private exchange – only on a public exchange.

To see what your state is doing regarding public marketplace (exchange) you should register for a quote on the www.RealtorsInsuranceMarketplace.com website.  We encourage you to contact a licensed SASid representative at 877-267-3752 who will help you decide which exchange (public or private) and/or health plan best suits your needs.

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How do I find my exchange?

You can either go to http://www.realtorsinsurancemarketplace.com/products/member-health-insurance-exchange/ or you can contact SASid’s professionally licensed staff at 877-267-3752 for advice and/or direction navigating your options.

State-based health insurance marketplaces, or exchanges, are a component of the Affordable Care Act (ACA).   States had the option of a) building a fully state-based marketplace, b) entering into a state-federal partnership marketplace, or c) defaulting to a federally facilitated marketplace.

Types of Public Exchanges (Marketplace):

  • StateBased Marketplace (SBM) – State is responsible for all functions (QHP, Premium fees, oversight/Monitoring, eligibility/enrollment, IT, outreach/education, consumer complaint, In‐Person assistance and the call center).
  • Partnership Marketplace – Marketplace is operated by the federal government, however State retains responsibility for Plan Management and/or Consumer Assistance functions.
  • Federally‐facilitated Marketplace – All functions are the responsibility of the federal government.


Remember, products and insurance companies may be different per exchange.

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What and when is Open Enrollment for the Affordable Care Act?

Individuals may enroll in a Qualified Health Plan during various timeframes throughout the year. The timeframes are the open enrollment period, and special enrollment periods (SEP).

  • The Open Enrollment period for 2017 coverage started on November 1, 2016 and runs through January 31st, 2017. During this timeframe you will be able to change your coverage at will, for any reason.
  • SEPs occur throughout the year, based on individuals’ special circumstances.

Special Enrollment Periods

Under certain circumstances, individuals may change QHPs outside of the annual open enrollment period. These SEPs are based on certain triggering events or exceptional circumstances. Events that permit a SEP include, but are not limited to:

  • Gaining or becoming a dependent;
  • Gaining status as a citizen, national, or lawfully present individual;
  • Loss of minimum essential coverage (e.g., loss of Medicaid eligibility, termination of a QHP), except if enrollment is terminated based on failure to pay premiums;
  • Loss of affordable employer-sponsored coverage;
  • Determination that an individual is newly eligible or ineligible for premium tax credits or a change in eligibility for cost-sharing reductions;
  • Permanent move to an area where different QHPs are available;
  • Other exceptional circumstances identified by the Marketplace.

In most cases, SEPs will extend for 60 days from the date of the triggering event. Under certain circumstances, such as the pending loss of minimum essential coverage due to the termination of a QHP, a SEP may begin before the triggering event takes place.

Special Enrollment Period for Marriage

As mentioned in triggering events, a SEP exists for marriage. This means that, if a qualified individual gets married, he or she has the chance to either enroll in a QHP for the first time, or add a spouse to the plan without waiting for the annual open enrollment period.

  • If a marriage occurs and the Individual Marketplace is notified before the last day of the month when the marriage occurred, coverage will begin the 1st of the following month.
  • If a marriage occurs and the Individual Marketplace is notified after the end of the month when the marriage occurred, coverage will begin the 1st of the month following the notification.

The Individual Marketplace would need to be notified within 60 days of a marriage for a spouse to be covered. If the 60-day deadline is missed, the spouse cannot enroll until the plan’s annual open enrollment period.

Special Enrollment Period for Birth or Adoption

Another important SEP exists for the birth or adoption of a child.

The effective date of coverage can be the date of the birth or the official date of adoption as long as the Individual Marketplace is notified in a timely manner.

The Individual Marketplace would need to be notified within 60 days of a birth or adoption for dependents to be covered. If the 60-day deadline is missed, the dependents cannot be enrolled until the plan’s annual open enrollment period.

Premiums would be pro-rated for the month, based on when the child was added to the policy.

NAR members should contact SASid’s professionally licensed staff at 877-267-3752 for advice and/or direction navigating their options.  Products and insurance companies may be different per exchange.

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Could there be rate increases on my health insurance?

Yes. Rates are reviewed on an annual basis and undergo a formal rate review process. All rate increases must be reviewed by the state insurance departments and receive approval before insurance companies can apply them to you. If your plan is going to experience a rate increase, your insurance company will notify you. You will have the opportunity to continue at the increased rate or select a different plan during open enrollment. Renewals take effect January 1st of the following year.

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Can I receive a subsidy for my health insurance under the Affordable Care Act?

Possibly.  It depends on your household income and the number of people living with you.

The Affordable Care Act (ACA) includes tax credits or subsidies for individuals and families to use toward qualified health plans found on public exchanges.  Subsidies will be available to qualified individuals and families that have previous reported incomes in the range of 138% to 400% above the Federal Poverty Level.  The below chart shows federal poverty guidelines based on family size:

Eligibility for Premium Tax Credits

Eligibility for the premium tax credit is based on household income and access to minimum essential coverage. The following summarizes the key eligibility standards for premium tax credits (tax credits that reduce the cost of insurance premiums).

You must meet the following criteria to be eligible for a premium tax credit:

  • You are not eligible for minimum essential coverage — including employer-sponsored coverage, Medicaid, CHIP, Medicare, and other forms of coverage — other than through the individual insurance market, unless your employer-sponsored coverage is not affordable or does not provide minimum value (based on by ACA standards).
  • You have an annual household income that is between 100% and 400% of the Federal Poverty Level (FPL), or below 100% of FPL for lawfully present non-citizens who are ineligible for Medicaid by reason of immigration status.
  • You are part of a tax household that will file a tax return for the coverage year and, if the tax household includes a married couple, that will file a joint return
  • You are eligible for coverage through a QHP

If you need guidance on the tax credits and subsidies SASid representatives are available to help you understand your best options.

Below is information on a subsidy estimate tool created by the Kaiser Family Foundation. It will provide you with an estimate tax credit.

The Kaiser Family Foundation health insurance cost and savings calculator

The health insurance costs and savings calculator we link to below provides only an estimate. Your final premiums and costs may differ from the estimates, perhaps significantly, depending on where you live and the coverage you select. You’ll learn your final costs for specific plans when you apply in the Health Insurance Marketplace.

Before you use the Kaiser Family Foundation calculator, there are a few important things to know:

  • The calculator provides a rough estimate of costs for insurance, based on national averages and factors that may not apply to you. It will give you an idea of what someone with circumstances like yours could pay for health insurance.
  • The calculator accounts for some factors that may determine plan costs in the Marketplace: age, family size, and tobacco use. Individual plans will weigh these factors differently to determine final prices.
  • The estimate doesn’t account for differences based on where you live, which will significantly affect Marketplace prices and offerings.
  • The prices are based on a plan in the Silver category. Plans in different categories will likely have higher or lower premiums.  (Plans found on public exchanges offer “metallic plans” with categories of Bronze, Silver, Gold, and Platinum.  These were developed and designed by the government based on essential offerings for qualification.)
  • You won’t be able to get your exact costs for a specific plan until you fill out a Marketplace application during Open Enrollment. Then you’ll see all of the plans available to you, compare features and prices side-by-side, choose a plan, and enroll. You should expect that your final cost will be different from the rough estimate provided here.

The calculator was created by the Kaiser Family Foundation, a non-profit research organization, for use by the general public. The Kaiser Family Foundation is solely responsible for the tool. The Kaiser Family Foundation has no connection with Kaiser Permanente or any health care provider.

SASid did not participate in the creation of this calculator. SASid does not warrant or guarantee the accuracy of estimates provided by the calculator.

If you’re ready to see the estimates, visit the Kaiser Family Foundation website and use the Kaiser Family Foundation’s health insurance costs and savings calculator.

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What do I do if my situation changes during the year?

There are special enrollment periods for people who have life changes or other situations.  These include losing minimum essential coverage; gaining a dependent or becoming a dependent through marriage, birth, adoption or placement for adoption; becoming a citizen, national or lawfully present individual; or becoming newly eligible for a premium tax credit or cost-sharing assistance.

If one of these life changes happens to you, you’ll have 60 days to go back to the Insurance Marketplace to enroll in a Qualified Health Plan (QHP).

If you missed your 60 days; there are still other insurance plans you can enroll into such as Temporary Health Insurance or REALTORS® Core Health Insurance.  Understand, though, that these plans do not meet the standards of a QHP and a penalty may still apply.

Members should contact SASid’s professionally licensed staff at 877-267-3752 for advice and/or direction navigating their options.  Products and insurance companies may be different per exchange.

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How does the Affordable Care Act (ACA) affect my HSA?

The Affordable Care Act did make some changes to Health Savings Accounts – also called HSAs – and how they will work:

  1. First, the law eliminated one’s ability to use money in their HSA account to buy over-the-counter drugs.
  2. The second big change is that the law increased the penalty for withdrawing funds from your HSA before you reach age 65. The early withdrawal penalty increased from 10% to 20%.

HSA-compatible plans are available for purchase through public and private exchanges (private only available during the annual Open Enrollment period) such as the REALTORS® Insurance Marketplace.

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Do I need to be on the same health insurance plan as my spouse?

No.  There is no requirement in the Affordable Care Act that spouses be on the same plan.

However, if you want to qualify for a premium tax credit to lower the cost, be aware that subsidies are based on your total household income level.

So, even though your spouse will not be covered by the subsidized insurance plan, their income will be calculated when determining the level of subsidy for which you are eligible.

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Am I eligible for the Affordable Care Act plans?

Basically, what puts the “affordable” in the Affordable Care Act plans is the presence of subsidies, which are available only on plans purchased via a public exchange. There are eligibility requirements if a person wants to receive these subsidies.

To qualify a person:

  • Must live in the U.S.
  • Be a U.S. citizen or national, or be lawfully present in the US
  • Have a household income between 133% and 400% of the Federal Poverty Level and
  • Cannot be currently incarcerated

If you do not meet these requirements, you may still apply for health insurance under the Affordable Care Act, but you would not qualify for government subsidies to help you pay for the coverage.  In this case you are probably better off purchasing through a private exchange during the Annual Open Enrollment period or through a private insurance agent (because there are more plans and carrier options in the private market).

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Can I still go on COBRA?

Yes, regulation has not changed for those who lose their job and wish to stay on their employer’s health insurance plan for up to 18 month – which is essentially how COBRA works.

What’s nice about the Affordable Care Act is that is gives people on COBRA the ability to apply for individual coverage without concern that their application can be declined.

Plus, people who opt out of COBRA and buy an individual insurance policy may qualify for low-income subsidies to help the pay for cost of their plan.

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Does the Affordable Care Act (ACA) provide any advantages to small businesses?

Yes, depending on your situation, ACA can make it possible for companies that may have previously been unable to afford insurance benefits to now offer it to their employees. Read on to learn more.

Small Business Health Options Program (SHOP) Features

Under the Affordable Care Act, during the first year of operation, small businesses that qualify for coverage through a SHOP will be able to offer their employees a single Qualified Health Plan (QHP) option. SHOPs will offer qualified small groups access to QHPs in each state, and will provide flexibility in the amount that members of the small group contribute toward the total premium.

To qualify for SHOP coverage, a business must:

  • Be located in a SHOP’s service area (generally a state)
  • Offer coverage to all full-time employees (those working an average of 30 or more hours per week)
  • Have at least one eligible employee on payroll
  • Have 50 or fewer full-time equivalent (FTE) employees on payroll
    • This methodology includes part-time employees, but not seasonal employees (those working fewer than 120 days per year)
    • While the Federally-facilitated SHOPs (FF-SHOP) must determine eligibility using the definitions above, State-based SHOP Marketplaces have flexibility in their counting approaches

The premium tax credits (subsidies) and cost-sharing reductions offered to individuals are not available to employers and families covered through a SHOP. However, employers meeting certain size and average wage requirements-see Shop Benefits section below—may receive a small business tax credit on their tax returns of up to 50% of the employer’s contribution to the premium.

 

SHOP Benefits

The SHOP Marketplace provides consumers, both employers and employees, with many benefits.

Only QHPs will be offered through the Marketplaces. Buyers will be assured that the available plans meet network adequacy and benefit design standards of the SHOP.

Premiums for the employers and employees will not be based on their health or medical history, but can only vary based on age, family composition, geographic area, and tobacco use.

A SHOP provides unbiased information and comparison tools for consumers. The tools available through the Marketplaces will help consumers with “apples to apples” comparisons among health plans.

The small business tax credit applies to small businesses with up to 25 FTE employees that pay employees an average annual wage below $50,000 and that contributes 50% or more towards employees’ health insurance premiums.

NAR members who are owners of small businesses should contact SASid’s professionally licensed staff at 877-267-3752 for advice and/or direction navigating their options.  Products and insurance companies may be different per exchange.

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What are Grandfathered Health Plans?

As used in connection with the Affordable Care Act: A group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions. (Note: If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may still be added to grandfathered group plans).

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Do small employers have to pay a tax or penalty for not offering health insurance to employees?

No. Under the Affordable Care Act, businesses with fewer than 50 full-time equivalent employees are not required to provide health insurance to their employees—nor will they face  tax penalties if they decide not to do so.

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Will I qualify for a Premium Tax Credit?

The Affordable Care Act provides a new tax credit to help you afford health coverage purchased through a government Marketplace.  Please contact one of our licensed representatives at SASid to help you determine your options.

Premium Tax Credit explained:  Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you’re due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return.

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Wouldn’t it be better for me to just pay the penalty for not purchasing a Qualified Health Plan?

The answer depends on your personal situation and whether or not you are comfortable paying a tax penalty.  Sometimes it can be favorable for an individual or family to purchase a non-qualified health plan and pay the penalty.  You should contact a SASid representative at 877-267-3752  to discuss your situation.

The Affordable Care Act (ACA) includes a provision called the individual shared responsibility payment, or more commonly known as the “individual mandate” or tax penalty. It is applied to individuals and families who do not have a Qualified Health Plan for longer than 3 months (these 3 months do not need to be consecutive), and this took effect Jan. 1, 2014.

Estimates from the Congressional Budget Office and Joint Committee on Taxation believe around 6 million Americans will choose to pay a penalty each year instead of purchasing health insurance.

Here is what you need to know about the Tax Penalty and how it is applied:

 

How to avoid the penalty-

To avoid paying the tax, individuals and families must purchase a health insurance plan which includes a minimum of 10 essential benefits.  These plans are known as Qualified Health Plans (QHP).  People who have other coverage through their employer or enrolled in government subsidized health plans (Medicare, Medicaid, CHIP, or TRICARE) do not need to worry about the tax.

Also, those uninsured individuals with incomes so low they aren’t required to file a federal tax return who cannot find coverage that cost less than 8% of their income do not face a penalty.  Others exempt from the penalty include members of Indian tribes, people whose religion objects to health insurance, undocumented immigrants, Americans living abroad, members of a health sharing ministry and people who are currently incarcerated.

 

The Penalty Amount-

The penalty for going without health insurance is either a flat fee or percentage of taxable income; based on whichever is greater.

For 2017, the Flat Fee is $695 per adult and $347.50 per child (up to $2,085) and the Percentage of Income is 2.5%.

 

Prorated Penalty-
If you were uninsured for less than three months of the year you will not need to pay the penalty.  After three months the tax applies to each month within a calendar year that you did not have coverage for yourself or a member of your household.  Insurance companies will provide documentation to prove you had coverage.

 

No criminal penalties-

Individuals who do not comply with the individual mandate to carry a Qualified Health Plan face no criminal penalties or threat of liens and seizures by the IRS.

 

How is the Penalty Amount Applied?-

The penalty will be determined when you file your income tax return and deducted from any potential refund. For 2017 plans, they will look at 2016 modified adjusted gross income (MAGI). The MAGI is different from Adjusted Gross Income (AGI) as it includes other deductions such as tuition fees or up to one-half of self-employment tax.

 

Should I consider a Non-Qualified Health Plan?-

Many people will consider plans which do not meet the 10 minimum essential benefits; referred to as Non-Qualified Health Plans.  These plans include limited indemnity medical, short term medical plans, and others.  Because they do not meet the federal government’s minimum standards these plans can be significantly cheaper.  Some experts believe many Americans will purchase a Non-Qualified Health Plan and pay the tax penalty in cost-saving efforts.

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What is a deductible?

deductible is the amount of expenses that must be paid out of pocket before an insurer will pay any expenses.  In general usage, the term deductible may be used to describe one of several types of clauses that are used by insurance companies as a threshold for policy payments.

Deductibles are typically used to deter large number of trivial claims that a consumer can be reasonably expected to bear the cost of. By restricting its coverage to events that are significant enough to incur large costs, the insurance firm expects to pay out slightly smaller amounts much less frequently, incurring much higher savings. As a result, insurance premiums are typically cheaper when they involve higher deductibles.

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What is a copay or copayment?

In the United States, copayment or copay (co-pay)is a payment defined in the insurance policy and paid by the insured person each time a medical service is accessed. It is technically a form of coinsurance, but is defined differently in health insurance where a coinsurance is a percentage payment after the deductible up to a certain limit. It must be paid before any policy benefit is payable by an insurance company. Copayments do not usually contribute towards any policy out-of-pocket maxima whereas coinsurance payments do.

Insurance companies use copayments to share health care costs to prevent moral hazard. Though the copay is often a small portion of the actual cost of the medical service, it is meant to prevent people from seeking medical care that may not be necessary (e.g.: an infection by the common cold). The underlying philosophy is that with no copay, people will consume much more care than they otherwise would if they were paying for all or some of it.

However, a copay may also discourage people from seeking necessary medical care and higher copays may result in non-use of essential medical services and prescriptions, thus rendering someone who is “insured” effectively “uninsured” because they are unable to pay higher copays. If the insured cannot afford the copay, they effectively have no insurance (high copays can cause a false sense of security). Thus there is a balance to be achieved: a high enough copay to deter unneeded expenses but low enough to not render the insurance useless.

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What is a gatekeeper?

Under some health insurance arrangements (mainly HMO or POS plans), a gatekeeper is responsible for the administration of the patient’s treatment; the gatekeeper coordinates and  authorizes all medical services, laboratory studies, specialty referrals and  hospitalizations.

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What is an indemnity plan?

A type of medical plan that reimburses the patient and/or provider as expenses are incurred.

Typically an indemnity plan will pay a set amount of benefit (example: $1,000 per day in hospital) described in the policy.

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What is a preferred provider organization (PPO) plan?

An indemnity plan where coverage is provided to participants through a  network of selected health care providers (such as hospitals and physicians). The enrollees may go outside the network, but would incur larger costs in the form of higher deductibles, higher coinsurance rates, or nondiscounted  charges from the providers.

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What is an exclusive provider organization (EPO) plan?

A more restrictive type of preferred provider organization plan under which employees must use providers from the specified network of physicians and hospitals to receive coverage; there is no coverage for care received from a non-network provider except in an emergency situation.

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What is a health maintenance organization (HMO)?

A health care system that assumes both the financial risks associated with providing comprehensive medical services (insurance and service risk) and the responsibility for health care delivery in a particular geographic area to HMO members, usually in return for a fixed, prepaid fee. Financial risk may be shared with the providers participating in the HMO.

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What is a point-of-service (POS) plan?

A POS plan is an “HMO/PPO” hybrid; sometimes referred to as an “open-ended” HMO when offered by an HMO. POS plans resemble HMOs for in-network services. Services received outside of the network are usually reimbursed in a manner similar to conventional indemnity plans (e.g., provider  reimbursement based on a fee schedule or usual, customary and reasonable charges).

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What is a physician-hospital organization (PHO)?

Alliances between physicians and hospitals to help providers attain market share, improve bargaining power and reduce administrative costs. These entities sell their services to managed care organizations or directly to employers.

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What is a fully insured plan?

A plan where the employer contracts with another organization to assume financial responsibility for the enrollees’ medical claims and for all incurred administrative costs.

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What are managed care plans?

Managed care plans generally provide comprehensive health services to their members, and offer financial incentives for patients to use the providers who belong to the plan. Examples of managed care plans include:

  • Health maintenance organizations (HMOs),
  • Preferred provider organizations (PPOs),
  • Exclusive provider organizations (EPOs), and
  • Point of service plans (POSs).

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What is a maximum plan dollar limit?

The maximum amount payable by the insurer for covered expenses for the insured and each covered dependent while covered under the health plan.

  • Plans can have a yearly and/or a lifetime maximum dollar limit.
  • The most typical of maximums is a lifetime amount of $1 million per individual.

NOTE:  The Affordable Care Act has removed the ability for insurers to limit plan amounts.

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What does maximum out-of-pocket expense mean?

The maximum dollar amount a group member is required to pay out of pocket during a year. Until this maximum is met, the plan and member shares in the cost of covered expenses. After the maximum is reached, the insurance carrier pays all covered expenses, often up to a lifetime maximum.

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What is a medical savings accounts (MSA) or health savings account (HSA)?

Savings accounts designated for out-of-pocket medical expenses. In an MSA, employers and individuals are allowed to contribute to a savings account on a pre-tax basis and carry over the unused funds at the end of the year. One major difference between a Flexible Spending Account (FSA) and a Medical Savings Account (MSA) is the ability under an MSA to carry over the unused funds for use in a future year, instead of losing unused funds at the end of the year.  Unlike FSAs, most MSAs are combined with a high deductible or catastrophic health insurance plan.

Click here for a more information regarding HSA/MSA

 

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What is an insurance premium?

Agreed upon fees paid for coverage of medical benefits for a defined benefit period. Premiums can be paid by employers, unions, employees, or shared by both the insured individual and the plan sponsor.

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What is a primary care physician (PCP)?

A physician who serves as a group member’s primary contact within the health plan. In a managed care plan, the primary care physician provides basic medical services,  coordinates and, if required by the plan, authorizes referrals to specialists and hospitals.

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What is a third party administrator (TPA)?

An individual or firm hired by an employer to handle claims processing, pay providers, and manage other functions related to the operation of health insurance.  The TPA is not the policyholder or the insurer.

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What are usual, customary, and reasonable (UCR) charges?

Conventional indemnity plans operate based on usual, customary, and reasonable (UCR) charges. UCR charges mean that the charge is the provider’s usual fee for a service that does not exceed the customary fee in that geographic area, and is reasonable based on the circumstances. Instead of UCR charges, PPO plans often operate based on a negotiated (fixed) schedule of fees that recognize charges for covered services up to a negotiated fixed dollar amount.

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What are flexible spending accounts or arrangements (FSA)?

Accounts offered and administered by employers that provide a way for employees to set aside, out of their paycheck, pretax dollars to pay for the employee’s share of insurance premiums or medical expenses not covered by the employer’s health plan. The employer may also make contributions to a FSA. Typically, benefits or cash must be used within the given benefit year or the employee loses the money. Flexible spending accounts can also be provided to cover childcare expenses, but those accounts must be established separately from medical FSAs.

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What is a flexible benefits plan (Cafeteria plan) (IRS 125 Plan)?

A benefit program under Section 125 of the Internal Revenue Code that offers employees a choice between permissible taxable benefits, including cash, and nontaxable benefits such as life and health insurance, vacations, retirement plans and child care. Although a common core of benefits may be required, the employee can determine how his or her remaining benefit dollars are to be allocated for each type of benefit from the total amount promised by the employer. Sometimes employee contributions may be made for additional coverage.

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What is REALTORS® Insurance Marketplace?

REALTORS® Insurance Marketplace is a comparative shopping site, just for members of the NATIONAL ASSOCIATION OF REALTORS®. Here, members can find a full roster of insurance plans and wellness products. Offerings include a private Major Medical health insurance exchange, a short term health insurance plan, a limited liability supplemental health insurance plan, accident deductible protection coverage, dental plans, vision plans, a free prescription drug savings card, and helpful links to additional insurance plans that offer savings to NAR members.

REALTORS® Insurance Marketplace is powered by SASid (Smart and Simple insurance development), in partnership with the NATIONAL ASSOCIATION OF REALTORS®, through the REALTOR Benefits® Program.

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How does REALTORS® Health Insurance Marketplace work?

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REALTORS® Insurance Marketplace makes health insurance easy to understand and convenient to buy. The Marketplace is a comparative shopping site that provides NAR members with a roster of health, dental, vision, and supplemental insurance plans and products, including a private Major Medical health insurance exchange, just for NAR members.

The private Members Health Insurance Exchange is an easy-to-use mini-site within this website. Here, members can easily obtain quotes and purchase insurance directly online or over the phone with assistance from a licensed benefits specialist.

Here’s how it works:

  • Insert your geographic and demographic information into the Marketplace quoting engine.
  • Based on the information you’ve provided, you will be shown the options available to you on both NAR’s private exchange for members, and either the federal government exchange or your state-based exchange. You can quote, shop, and enroll directly online.
  • If you would like assistance you can call a licensed benefit specialist at 877-267-3752. They are available to you both during the enrollment process and afterwards as well, if you need help later on. Personal consultations are always complimentary.

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