Senior Care Plus Answers to Your Questions
Q. What is a HMO?
A.
HMO stands
for Health Maintenance Organization. Senior Care Plus contracts with doctors and other providers. You select from among these providers to receive authorized medical care. Present your Senior Care Plus membership card, and all you pay is your copayment, coinsurance, or deductible, if applicable, for the services you receive. Senior Care Plus pays the remainder of the bill.
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Q. Who is eligible for coverage?
A. Senior Care Plus members who meet eligibility guidelines as defined in the Senior Care Plus Evidence of Coverage (EOC) booklet are eligible for health-care coverage.
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Q. How do I apply for coverage?
A. Fill out all sections, sign, and date your "Senior Care Plus Application for Enrollment" and return it to Senior Care Plus. Please call the Senior Care Plus Enrollment Department at 775-982-3158 for more information.
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Q. What is my deductible for medical services?
A. There is no deductible to be satisfied for services covered by the Value Plan. If you elect the Plus Package, there is a $50 calendar year deductible for Basic and Major dental services. Please refer to your Evidence of Coverage for more information.
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Q. What is my "Copayment",
"Coinsurance", and "Deductible" (the amount that I pay)?
A. Some benefits have a copayment, a set amount you pay when you access services. Other benefits have
coinsurance, a percentage
you pay when you access services. Some benefits have no copayments or
coinsurance at all. Inpatient Hospital Services, Inpatient Mental Health Services, and
Skilled Nursing Facility Services have a per stay copayment amount. See your Summary of
Benefits and Evidence of Coverage for specific information regarding your
financial responsibility when using our plan.
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Q. Do I have to fill out a claim form? What should I do if I receive a bill?
A. You do not have to fill out any claim forms for care received from authorized and participating providers. The only bills for which you are responsible are your copayments, coinsurance, deductibles, or bills for unauthorized services acquired from a noncontracted provider. If you receive a bill for which you believe you are not responsible, send it to Senior Care Plus to process or call the Senior Care Plus Customer Services Department at 775-982-3112, for assistance.
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Q. What is my lifetime maximum benefit?
A. The Value Plan does not have a lifetime maximum benefit. However,
some benefits have annual or quarterly maximums, including Outpatient Prescription Drugs. See your Summary of Benefits and Evidence of Coverage for limitations.
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Q. What if the charges are higher than "usual and customary"?
A. You do not have to be concerned about "usual and customary" charges with the Value Plan. Senior Care Plus has contracted fees with participating providers for all services.
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Q. How are prescriptions covered?
A. If Senior Care Plus provides your prescription benefit, you must have a participating pharmacy fill your prescriptions (refer to your Provider Directory). The pharmacy will fill prescriptions to the amount prescribed for up to a 30-day supply.
For prescriptions that you need to take for more
than a 30-day period, Senior Care Plus offers a Mail Order Prescription Drug
Program, which provides for your prescription needs and delivers them directly
to your door. For more information refer to your Prescription Drug Rider or
contact the Senior Care Plus Customer Services Department.
Since Senior Care Plus uses a Formulary (a list of approved medications), your prescribed medication must be on the Formulary to be covered. Non-Formulary drugs are not a covered benefit; you must pay in full for these drugs. For Formulary generic drugs, you will pay a low copayment per prescription. Brand-name drugs are not covered unless you elect the Plus Package which includes expanded prescription coverage.
For a Formulary brand-name drug that has an approved generic-equivalent drug on the Formulary, you will pay the brand-name copayment amount plus the difference in cost between the generic drug and the brand-name drug.
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Q. I am leaving for a two-week vacation, and my prescription will run out before I return. What can I do?
A. Your pharmacist may contact our Pharmacy Prior Authorization Line to request a special authorization number. With that number, the pharmacist will fill your prescription for an additional 30-day fill with an additional copayment.
| Q. How can I replace my lost Senior Care Plus membership card? |
|
A. You can
request a new membership card by calling our Customer Services 
Department at 775-982-3112, or 800-336-0123. Senior Care Plus
will send a replacement card to your home address within seven to ten
working days of your request.
This is a sample of one type of Senior
Care Plus membership card. Your card may contain different information to
reflect the benefit plan that you
selected.
|
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Q. I will be moving soon. How do I notify Senior Care Plus of my new address?
A. Senior Care Plus must have your correct address and telephone number. We notify members about any referrals, program or physician changes, and claims status by mail. Also, we want to make sure you receive each issue of our newsletter, For the Smarter Generation. Please contact our Customer Services Department before you move, or mail us a change of address card (available at your local post office).
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Q. Am I required to select a Primary Care Physician?
A. Yes. Senior Care Plus
cannot process your Application for Enrollment without a Primary Care Physician
selection. If you do not indicate a Primary Care Physician, we will select one
for you. You always retain the right to change your Primary Care Physician.
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Q. What is the role of my Primary Care Physician?
A. Your Primary Care Physician's primary responsibility is to provide, arrange, and coordinate all aspects of your health care.
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Q. I do not know any of the doctors on your provider list. What should I do?
A.
Our
Customer
Services Representatives will verify which providers are currently accepting new patients and provide you with some basic information, such as the type of practice, location, office setting (clinic vs. private practice), and appointment procedures. You can also call the 24-hour Hometown Health Hotline at 775-982-5757 or 888-324-3243, option 1.
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Q. Is my Primary Care Physician given any incentive not to send me to a specialist or not to provide me with appropriate care?
A. No. Your doctor is given incentives to provide you with appropriate care. Senior Care Plus reviews the care that your Primary Care Physician provides on a regular basis to monitor the frequency that he or she refers care and to be sure you are receiving appropriate care.
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Q. Do I need a referral for specialty care?
A. Yes. You need a referral from your Primary Care Physician before receiving any specialty care. If your Primary Care Physician determines that you need medical care or services from a specialty-care provider, he or she will make a referral from Senior Care Plus to a participating plan provider. This referral will indicate how many visits, the time period, and location. Contact Senior Care Plus if you have not received your written referral in a timely manner.
Exception: Most OB/GYN care does not require a Primary Care Physician referral.
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Q. What is the role of a specialty care physician?
A. A specialty-care physician provides certain specialty medical care upon referral from your Primary Care Physician.
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Q. Does Senior Care Plus cover physicals?
A. Senior Care Plus covers routine yearly health assessments, including tests normally made with the examinations. Senior Care Plus does not provide coverage, however, for a physical for work, sports participation, insurance, school attendance, or any kind of licensure.
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Q. I would like to see a chiropractor. Does Senior Care Plus cover that?
A.
Your Primary Care Physician will request a referral from Senior Care Plus, and you must receive a written referral from Senior Care Plus prior to using any specialty services. Chiropractic services are covered when covered by traditional Medicare. Your office copayment applies.
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Please refer to your Evidence of Coverage booklet for a detailed description of your benefits.
